Transcript Paradigm Shift – Inpatient towards outpatient and

Paradigm Shift –
Inpatient towards
outpatient and
community oriented care
on heart failure patients
Prepared by Camille K T HO
Acknowledgement
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Dr. S C LEUNG (HCE)
Dr. W H CHOW (COS)
Dr. E CHAU (SMO)
Ms C L LEE (DOM)
Ms W HUNG (GMN)
Prof. F Wong
All members of the team (CMU)
Introduction
• Heart failure is a common and costly
cause of admissions to hospitals each
year
• The cost of heart failure is increasing
because the population is living longer
(Stewart et al 2002)
Introduction
Patients with congestive heart failure
=
$$$
Unplanned admissions
Unplanned follow ups
Reduce quality of life
Significant morbidity
In Hong Kong, the overall incidence was 0.7
per 1,000 population admitted to hospitals
due to heart failure, with plenty of
readmissions and unplanned follow up.
These preventable negative factors include
noncompliance with medications or diet,
inadequate discharge planning or follow
up, and failure to seek medical attention
promptly when symptoms recur.
(Leung et al 2004)
Purposes of the program
• Empowering the patients in self-management of
their heart failure symptoms
• Improve their quality of life
• Promote their care in the community
• Reduce the unplanned readmissions and follow
up
Expected Results
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↑↑ Treatment compliance
Better symptoms control
Increase exercise capacity
Improve NYHAFC
↓↓ frequency of unplanned follow up
↓↓ unplanned readmission
Transfer back to general cardiac care
Methods
Participants’ selection criteria
• >18
• M/F
• NYHAFC 2-4
• CAN READ AND WRITE CHINESE
• PRIMARY DIAGNOSIS OF HEART
FAILURE
• REGULAR FU in GH Heart Failure Clinic
Methods
Flow for Heart Failure Clients Home-based Monitoring Program
Initial assessment by SMO/Patient Educator (PE)
of CMU, GH, in the HFC for suitable participants
unsuitable candidates
suitable candidates
Baseline assessment of patient’s condition obtained
PE (Nurse) conduct patient education program
for client enrolled in the home-based monitoring program
(Refer to appropriate
allied health care professionals prn)
Patient home–based Monitoring program
with Tele-nursing by PE
continue follow up in the HFC
Methods
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Assessment protocol
Physical examinations
Daily body weight
Daily fluid balance
Drug compliance
Dietary compliance
Exercise tolerance
Unwanted habits
Quality of life
assessment
Methods
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Apparatus and Measuring Instruments
Blood pressure monitoring device
Logbook with fluid balance charts
Quality of life assessment test
Weight Scales
± Cardiopulmonary exercise test
Data analysis of the self-management
program
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Intake and Output balance
Symptoms control
Exercise capacity
Behavior modification
Drug compliance
Dietary compliance
NYHAFC status
The frequency of unplanned FU / hospitalization
The length of follow up period
Results
Patient Population
• From March 2004 to September 2004
• 31 patients within the selection criteria were
recruited at convenience sampling
• Age
• 20 – 65
• Mean age 47.3 ± 10.9
• Sex
• Male 26
• Female 5
Results
Marital status
• Single 7
• Married 20
• Divorce 1
Results
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Etiology of heart failure were:
Ischaemic cardiomyopathy = 12.9%
Dilated cardiomyopathy = 70.9%
Acquired valvular disease = 12.9%
Others = 3.3%
Results
Pre program
Mean ejection fraction
= 34.54 ± 10.8%
Post program
= 42.05 ± 11.8%
p=0.003
NYHAFC
• Class I 0%
• Class II 16.1%
• Class III 71%
• Class IV 12.9%
6.9%
79.3%
13.7%
0%
p<0.001
Results
Pre program
Post program
Body weight
• 70.29 ± 14.2 kg
• 70.52 ± 13.8 kg
P=0.281
Results
Pre program
Post program
Average FU duration
• 3 – 15 weeks
• 8 ± 3 weeks
• 5 – 26 weeks
• 14 ± 4 weeks
p<0.001
Results
Pre program
Post program
VO2 max
• 17.85 ± 5.04
L/kg/min
• 19.91 ± 3.40
L/kg/min
p=0.093
Results Minnesota Living with
HFQ
Pre program
Post program
• 2 - 88
• 33.7 ± 10.31
• 2 – 59
• 19.4 ± 10.9
p<0.001
outcome of the patient
Results
80
Consequences
of the patients
in their future
care
60
40
Percent
20
0
continue fu
inactive/long fu
referred back to AC
outcome of the patient
heart transplant
dead
Discussion
• As evidenced by this project telephone patients
on a weekly basis to monitor their status, guide
by a standardized protocol and by asking the
same questions with each phone call, Patient
educators can quickly detect improvement or
deterioration. If the condition is worsening, early
intervention can be implemented, often avoiding
acute exacerbation and hospital admission.
Lessons Learned
• Development of the shifting to Community
Oriented Care HF program was
challenging,
• Outpatients enrolled in this program
greatly benefit from a decrease in
recidivism and from improved functional
status, physical endurance, and quality of
life
Limitations
• This study was a non-randomized trial, the
participants willing to join this program were self
motivated that may overestimate the benefit of
this program
• It was a relatively small study, larger studies
involving more patients are needed to confirm
the efficacy and to identify which patient groups
will benefit the most from this program
Conclusion
• As evidenced by this project, patients
could be empowered to participate in their
own care at home and in the community
by adequate education and continuous
tele-care which could promote healthy
behavior as reflected by the high
adherence to drugs and dietary regimen
and better symptoms control among our
clients.