Developing a system Developing a system of careof care

Robert D. ReidRobert D. Reid

University of Ottawa Heart University of Ottawa Heart InstituteInstitute

breid@ottawaheart.cabreid@ottawaheart.ca

A brief history…A brief history…

No. of Participants

0586 482 333 315 324 235 576 604 595 602 835

1600

6000

0

1000

2000

3000

4000

5000

6000

7000

'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05

Year

“Tickers”

Open OP ClinicAdd: 0.5 FTE

nurseIP program

New leader, 1.0 FTE nurse

Institutional approach

Regional network

What changed to allow What changed to allow for dramatic growth in for dramatic growth in

capacity?capacity?

Success comes from…Success comes from…

doing doing ordinaryordinary things things extraordinarilyextraordinarily well…well…

in a in a systematicsystematic way… way… at the at the right timeright time…… using using effectiveeffective interventions… interventions… with measured with measured outcomesoutcomes…… within a within a networknetwork of care… of care… and a and a cultureculture of prevention. of prevention.

InterventionIntervention Lives SavedLives Saved NNTNNT

Smoking CessationSmoking Cessation 328,400328,400 9 9

Lipid LoweringLipid Lowering 132,777132,777 34 34

BP ControlBP Control 63,282 63,282 31 31

ACE Inhibitors (CHF)ACE Inhibitors (CHF) 11,000 11,000 N/AN/A

ß Blockers (MI)ß Blockers (MI) 17,023 17,023 120120

ASA (MI)ASA (MI) 10,365 10,365 143143

Coumadin (A.Fib)Coumadin (A.Fib) 3,418 3,418 2,014 2,014

Projected Outcomes of Preventive Projected Outcomes of Preventive InterventionsInterventions

Doing ordinary things, Doing ordinary things, extraordinarily well…extraordinarily well…

IMPACT =IMPACT =

REACH *REACH *

EFFECTIVENESSEFFECTIVENESS

The Untapped National Potential

• 2,770,128 inpatient hospitalizations in Canada (02/03)

If 20% hospitalized pts. smokers

= 550,000 patients

““I rob banks because that’s I rob banks because that’s where the money is”where the money is”

Willie Sutton

In a systematic way…In a systematic way…

Documentation of smoking status of Documentation of smoking status of everyevery patient admitted to University patient admitted to University of Ottawa Heart Instituteof Ottawa Heart Institute

Intervention for Intervention for everyevery smoker smoker

The University of Ottawa The University of Ottawa Heart Institute In-Patient Heart Institute In-Patient

Smoking Cessation Smoking Cessation ProgramProgram

> 6500 admissions/year> 6500 admissions/year >1300 smokers identified (20%)>1300 smokers identified (20%) Cessation counseling provided to 90%Cessation counseling provided to 90% An absolute increase of 15% in long An absolute increase of 15% in long

term cessation ratesterm cessation rates 195 new quitters195 new quitters

Prev Med 2003; 36(6):710-20

At the right timeAt the right time

Readiness to change

59

33

810

30

60

0

10

20

30

40

50

60

70

PC C P

Stage of change

Per

cen

t o

f sa

mp

le

Population sample

Cardiac-In-hospital

Using effective Using effective interventions…interventions…

Brief or intensive counseling Brief or intensive counseling PharmacotherapyPharmacotherapy Self-help materialsSelf-help materials Follow-up contactsFollow-up contacts

Interactive voice response (IVR) Interactive voice response (IVR) technologytechnology

Linked to community Linked to community resources/programsresources/programs

AskAsk

AdviseAdvise

AssessAssess

AssistAssist

ArrangeArrange

““A health professional’s advice to stop smoking increases A health professional’s advice to stop smoking increases the rate of the rate of smokingsmoking cessation by approximately 30 percent.” cessation by approximately 30 percent.”

The Power of a Brief The Power of a Brief InterventionIntervention

Within a network of Within a network of care…care…

Hospitals

1o CareProviders

CommunityAgencies

Public Health

““A thousand ways to A thousand ways to make love but no make love but no

lovers”lovers”

With measured With measured outcomes…outcomes…

To demonstrate value for moneyTo demonstrate value for money To provide feedback and motivationTo provide feedback and motivation To fine-tune your programTo fine-tune your program To benchmarkTo benchmark

…and great stories that bring your program to life

A Culture of PreventionA Culture of Prevention

Smoking CessationSmoking Cessation

… … single most powerful single most powerful preventionprevention

Intervention in clinical practiceIntervention in clinical practice

Types of influence for Types of influence for changechange

Organizational

Policy

Social

Social influencesSocial influences

ChampionsChampions Culture of preventionCulture of prevention Feedback on performanceFeedback on performance

Policy influencesPolicy influences

Smoking cessation as a quality indicatorSmoking cessation as a quality indicator Inclusion on care mapsInclusion on care maps Standard ordersStandard orders Allocation of human resourcesAllocation of human resources

Organizational Organizational influencesinfluences

Documentation of smoking status (a vital Documentation of smoking status (a vital sign)sign)

Staff trainingStaff training Availability of self-help materialsAvailability of self-help materials Availability of pharmacotherapyAvailability of pharmacotherapy Follow-upFollow-up Data trackingData tracking Links to community resourcesLinks to community resources

Provincial quit lineProvincial quit line Referral to tobacco cessation specialistsReferral to tobacco cessation specialists

ChecklistChecklist

PolicyPolicy Quality indicator?Quality indicator? Care map(s)?Care map(s)? Standard orders?Standard orders? Designated Designated

people?people?OrganizationOrganization Documentation?Documentation? Training?Training?

Self-help materials?Self-help materials? Pharmacotherapy?Pharmacotherapy? Follow-up?Follow-up? Data management?Data management? Links?Links?SocialSocial Champion?Champion? Culture of Culture of

prevention?prevention? Feedback?Feedback?

Success comes from…Success comes from…

doing doing ordinaryordinary things things extraordinarilyextraordinarily well…well…

in a in a systematicsystematic way… way… at the at the right timeright time…… using using effectiveeffective interventions… interventions… with measured with measured outcomesoutcomes…… within a within a networknetwork of care… of care… and a and a cultureculture of prevention. of prevention.