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Integrating AMI Care Across a Healthcare Service System

Integrating AMI Care Across a Healthcare Service System. Safer Healthcare Now National WebEx October 19 th , 2009 Diane Shanks and Leila Lavorato. Regionalization. Occurred in 1995 Influenced “systems” approach to care delivery Identified gaps

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Integrating AMI Care Across a Healthcare Service System

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  1. Integrating AMI Care Across a Healthcare Service System Safer Healthcare Now National WebEx October 19th, 2009 Diane Shanks and Leila Lavorato

  2. Regionalization • Occurred in 1995 • Influenced “systems” approach to care delivery • Identified gaps • Provided opportunities to address gaps through collaborative approach and processes

  3. Program Management • Regional administrative and quality oversight • Facilitated the standardization of policies, protocols, and equipment • Facilitated a regional approach to data collection/management and analysis • Provided clinical expertise • Provided a strong collaborative network of clinical experts to support a health “system” approach to care

  4. Multidisciplinary Committee • Membership included key departments/services/individuals influencing care delivery to the AMI patient population • Representation from across the continuum from pre-admission to community care • Regional representation

  5. Strategies • Clinical Pathway • Standardized physician order sets/forms • Staff education and training • Indicator collection and analysis

  6. Performance/Quality Indicators • Challenges of data collection • Multiple sources/care environments/sites • Resource limitations • Timeliness • Variety of indicators required • Utilization • Quality • Performance

  7. Approach and Heart Alert • Electronic databases for the collection of clinical data of acute coronary syndrome patients admitted to a healthcare facility for coronary care and procedures • Established in Alberta, but has expanded across Canada

  8. Approach and Heart Alert • Provided the opportunity: • to capture data in one system • to contribute to Provincial/National database • to improve the continuity and timely exchange of vital patient information between referral regions

  9. Implementation • Developed processes for data collection and entry in a timely manner • Implemented region wide • Implemented within current resources • Developed (with the support of Approach resources) administrative reports for our own organizational purposes • Implemented October 1, 2007

  10. BUILDING HEALTHY LIFESTYLES CARDIAC REHAB PROGRAMOur Patient’s JourneyPresented October 19, 2009Leila Lavorato

  11. Referral • Automatic - ACS pathway • Health Care provider • Self / Family • Initial Intervention • Inpatient visit / introduction • Education Package • Intervention screening

  12. Education Series • Heart CHEC • “What Now?” • “What Next?” • BHL Class Calendar – free, no referral needed • Generic • Disease specific topics • Assessment • Program Nurse • Coaching model / Motivational interviewing • Set SMART goals / Develop action plans • Consult programs / services

  13. Exercise testing/screening • BHL program referral / Pre Requisite / Physician approval • Pre Testing / Screening • 6 Minute Walk Test • Timed Up and Go • Body Composition • Establish Exercise Level I, II, III • Identify activity tolerance / physical limitations • Determine Site or Home based

  14. Exercise programming • COMMUNITY SITE • Emergency procedures • Levels I, II, III • Mixed groups • Led by RN, RT, EP • 2 / week for 3 months + home exercise • Structured, monitored moving to self managed activity • Aerobic, Muscle Strength, Stretching exercises - HOME BASED • Fit and Functional Class / Lifestyle Journal • Regular check- ins • Same follow up and testing

  15. Follow up • 3, 6, 12 months • Exercise Testing • Cardiac Rehab specific Group Visit FOR MORE INFORMATION BUILDING HEALTHY LIFESTYLES CARDIAC REHAB PROGRAM CALL TOLL FREE 1 866 506 6654 or direct 1 403 388 6329

  16. Patient/Family Health Care Provider Physician BUILDING HEALTHY LIFESTYLESPROGRAM MODEL Building Healthy Lifestyles Referral to home base - NAVIGATED Secondary / Tertiary Prevention Primary Prevention - Incident Report - Progress Report Disease Specific Programs - Assessments – Education - Management Diabetes Acute Coronary Syndrome - Cardiac Heart Function Clinic / Network Clinical Nutrition Chronic Respiratory Risk Factor Mx Weight Loss Building Healthy Lifestyle Group Classes THERAPEUTIC EXERCISE REFERRAL PRE REQUISITION COMPLETION PHYSICIAN APPROVAL DISEASE SPECIFIC PROGRAM OUTCOMES EXERCISE TESTING FIT & FUNCTIONAL Level I HOME EXERCISE Levels I, II or III - Endurance - Muscle Strength - Flexibility Level II Level III 3 month POST PROGRAM OUTCOMES 6 Month & 12 Month Testing & Follow Up COMMUNITY/HOME

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