Rapid advances in surgical and catheter techniques over the last two decades improve quality of life and survival in individuals receiving these therapies.4 Awareness of HVD and coordination of care for timely diagnosis and referral for intervention can be accelerated by coordination of care incorporating advances in cardiac techniques including echocardiography (cardiac ultrasound). [...] Many other areas of care have been developing and implementing more integrated approaches that manage the entire patient journey and support more seamless hand-offs to the benefit of the patient, and the system. [...] Some Overall Goals for moving to spoke-hub-mode model: • There is early identification of heart valve disease and diagnosis and patient-centred planning for heart valve disease patients should move more upstream and include prevention programs to reduce complications in at-risk populations) • Admissions for interventions are planned and unnecessary ED visits and admissions are prevented. [...] • Plan: identify the members of the core inter-professional care team and ensure that both health care professionals and the patient/ caregiver understand and has access to the care plan and resources. [...] In the United States, 4R models (Right information and Right care for the Right patient at the Right time) are being explored in care pathways for BC, and for optimizing teamwork and care delivery starting at diagnosis.51,52 This model is utilizes principles from business/project management and as such, manages a BC patient using having a physician and nurse team develop a care project plan (“care.
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Table of Contents
- Contributing authors 2
- Please direct any inquiries about this report to John Sproule Senior Policy Director Institute of Health Economics jsprouleihe.ca. 2
- Funding 2
- Section One Recommendations 9
- Organizational Considerations 11
- Spoke 12
- Detection of HVD risk and symptoms often in primarycommunity care eg. family physician represents a . 12
- Hub 13
- Specialty diagnostics and regional assessmentreferral e.g. cardiologists echocardiogram diagnostics represents a . 13
- Node 14
- Tertiary care hospitals providing specialized HVD interventions e.g. surgical or transcatheter valve repairreplacement represent a . 14
- System Level Supports 15
- Section 2 Background Material 16
- Heart Valve Disease Burden 16
- Prevalence 16
- Diagnosis and Treatment 17
- Health Outcomes 18
- Section Three Emerging Models of Integrated Care 19
- Heart Valve Disease Global and National Calls to Action for more integrated care 21
- Breast Cancer Integrated Care Pathways 25
- Chronic Kidney Disease Shared Care and Regional Network Models 27
- We need purposeful shared care development. If youre going to develop teams you cant just flip a switch and put a bit of extra money in and hope by serendipity it will happen. 29
- Not everyone needs to see a heart team. Ongoing issue is patients are seen too early and sometimes too late. - Cardiologist 29
- We need to make collaboration easy and avoid not my responsibility responses along the patient journey.- Cardiologist 29
- Community cardiac surgical center can increasingly do more complex procedure. The tertiary hospital node is not the only game in town. 29
- Key supports will include enhanced primary care supports strong system performance metrics and engaged and informed provider and health system administrators. 29
- Nodes will also act as Hubs in many cases but we need to distribute diagnostic and surveillance more closely where people live while focusing special centers for interventions 29
