PHASE 1 THE PROCESS MEASUREMENTS PARTICIPANTS GAP TOOLKIT MEASUREMENT DATA PHASE I This Oregon Guidelines Applied in Practice project was proposed in 1999 and began in 2001. This proposal was a response to an invitation from the American College of Cardiology. The goal is to improve cardiac care by following the published Guidelines. The Oregon HF-GAP chose to focus on heart failure because: Heart failure is increasing frequency affecting 1.5 million Americans Costs of care for heart failure patients are rising rapidly Clinically meaningful gaps existed between practice and published guidelines Increased adherence to the published Guidelines for Heart Failure management, will improve the lives and life expectancy of people with heart failure care. The American College of Cardiology Foundation has promoted GAP projects (Michigan, Oregon, Alabama) with foresight and a willingness to become involved in improving the quality of medical care. The Oregon HF-GAP differs from other ACC GAP projects with an emphasis on outpatient care and on chronic disease management. The project a multiphase effort enlisting collaboration and participation across the clinical practice spectrum and geography the state of Oregon. Phase one involves expert heart failure cardiologists working in the practice community. These cardiologists are charged with developing and testing care improvement methods and/or techniques to be applicable to and to be made available to all clinicians caring for heart failure patients. To begin and in order to define objectives for the project, the Oregon HF-GAP Steering Committee first identified five key barriers in heart failure care: Patients often stop taking medications because they don't understand the benefits No short but comprehensive patient overview of heart failure was available Patient adherence to treatment plans was poor Self care instructions are rarely clear and concise Treatment guidelines for clinicians were long, complex and difficult to use Medical records were not designed to provide cues that encourage adherence of care to guidelines With this base, the steering committee and project participants began this first phase of this HF-GAP project focused on the development and then testing of "tools" that make it easier for clinicians to administer consistent guideline-driven care to patients with heart failure. Specifically,the objectives of this phase were: To develop a set of "tools" for clinicians and heart failure patients, and To stimulate cardiologist involvement in this and subsequent phases of improving heart failure care. THE PROCESS Working collaboratively toward such goals is a new process to clinicians. Therefore the HF-GAP project employed numerous processes and devises to facilitate group work and creation of useful tools. Participants worked as teams, principally a nurse and cardiologist in each participating practice. They connected and shared their ideas and experiences through these process aids: Facilitated Learning Sessions Lectures by authorities in specific areas of chronic care management and patient participation Introductions to Systems Change Methods and models for chronic care Teleconferences On site visits Individual practice trials of prototype tools Email Listserv Project face to face meetings THE "TOOLS" "Tools" developed through this process address of a broad spectrum of clinical heart failure care practice and reflects abroad range of input from clinical practice settings widely separated across Oregon contributes to the relevance of these tools to our practice demands. This Tool Kit now comprises: THE OREGON HEART FAILURE GAP TOOLKIT Tools for Patients How to Care for Your Heart - a brochure Heart Care Instructions Heart Care Medication Information Heart Care Medication List Tools for Clinicians Clinician's Guide to Heart Failure Care - key points from the guidelines Increase your Patients' Success - uncommon ideas that facilitate patient compliance Sample Heart Failure Visit Template Tools for Patient & Clinician Collaboration My Heart Failure Goals - a written contract between clinician and patient HF-GAP Discharge Instructions Tools for Data Management The HF-GAP Patient Registry Measurements: Although the "Tool Kit" is collaboratively developed, testing of the tools is valuable. Testing uses baseline and post intervention measurement. Baseline data show that Oregon cardiologists follow these guidelines quite well. Therefore we expected little increase in response to intervention. However, the testing the measurement techniques in cardiology practices also provided experience with identifying the data elements in clinical records in a variety of practice settings using paper and electronic records. A chart abstraction from each participating practice provided baseline data on practice patterns before the tools were introduced. The measurement sample is limited to cases with systolic dysfunction. Nurse reviewers collected the following data: Demographics: Electronic Medical Record Use Heart failure Template Use Patient registry Use LV function assessment Heart Failure Type Co-morbidities Functional Status Measurement Self management Goals Use ACE drug, dose, contraindications ARB drug, dose, contraindications Beta blocker, drug, dose, contraindications Warfarin use for Atrial Fibrillation, contraindications Interim data after partial tool implementation are now available. Subsequent data measurement may be forth coming. Important changes followed introduction of the tools, even in this early sample. Nevertheless, opportunity for improvement remains even among these experts and especially in the realm of patient participation, patient goal setting, and the use of specific measures of patient functional capacity. These results do affirm the validity of the tools this project has developed and lend support for broader implementation. These results and feedback from the participants affirm the value of the HF-GAP tools and lend support for broader implementation. The Oregon HF-GAP Steering Committee Principal Investigator: Mark Huth MD FACC Co-Principal Investigator: Ruth Medak MD Committe Members: Kathy Crispell MD FACC Richard Schaefer MD FACC Kirk Walker MD FACC Project Advisors: Leonard Christie MD MPH FACC Allen Johnson MD Participating Clinical Teams Jerold Hawn MD FACC Donna Cash NP Eugene, Oregon Louise Kremkau MD FACC Ranae Ratkovec MD FACC Debbie Dorst NP Portland, Oregon D. Thomas Combs MD FACC Nancy Hilles NP Bend, Oregon Kirk W. Walker MD FACC Sue Snider RN Salem, Oregon Mark Huth MD PhD FACC Diedre Goldberg RN Medford, Oregon Richard Schaefer, MD FACC Linda Nisbit NP, Renee Heath Medford, Oregon Kathy Crispell MD FACC Cindy Quale RN Portland, Oregon Participating Practice Partners Bend, Oregon Bruce Brundage MD Bruce McLellan MD Eddy Young MD Hugh Adair MD J. Timothy Hanlon MD Nicholas Dienel MD Eugene, Oregon Joseph Chambers MD Dennis Gory MD John Grundy MD Beth Karolle MD Richard Padgett MD Portland, Oregon Anthony Garvey MD Bradley Evans MD Robert Hodson MD Manohar Punja MD Hari Saini MD Mathew Voorsanger MD Jody Welborn MD Patrick Bergin MD Douglas Dawley MD Dale Hirsch MD Ronald Petersen MD Steven Reinhart MD John McAnulty MD Raymond Herschberger MD Medford, Oregon David Foster MD Todd Kotler MD David J. Martin MD Minor Mathews MD Mark G. Moran MD Brian J. Morrison MD John Forsyth MD Brian Gross MD Bruce Patterson MD Steven Schnugg MD Oregon Heart Failure GAP Toolkit Clinician Tools: 1 - Clinician Guide to Heart Failure Treatment - For primary care clinicians [2-sided- color brochure]. HF Clinician Guide[color] [pdf document] 2 - Tips for Increasing Effectiveness of Interactions with Patients HF Clinician Tips [color] [color] [pdf document] HF Clinician Tips [b&w] [pdf document] 3 - Sample Heart Failure Visit Template [b&w] HF Sample Visit Template [b&w][pdf document] Patient Tools: 4* - How to Care For Your Heart [tri-fold brochure with space available for customizing] GAP and OMPRO logos - [color] [2] GAP logo - Color [4] 5* - Heart Care Instructions - Instructions and information about drugs [2-sided color b&w] HF Care Instructions [c][pdf document] HF Care Instructions [b&w] [pdf document] 6* - Heart Care Medication Information [color b&w] HF Med Information 14 Font [b&w] [pdf document] 7* - Medication List [color b&w] HF Medication List [c] [pdf document] HF Medication List [b&w] [pdf document] 8* - Self-Management Goal Setting Tool Color ways patients can help themselves [color - b&w] HF Self Management Goals GAP [c] [pdf document] HF Self Management Goals [b&w] [pdf document] 9* - Hospital Discharge Information for Patients - comparison of care to guidelines [b&w] HF Hospital Discharge Information [b&w] [pdf document] Information Support: 10 Heart Failure Management Registry (Microsoft Access 2000) The tools are available in PDF format or may be ordered directly from the printer print@powellmmp.com And for added resources visit http://www.ompro.org/professionals/improvement_tools/heart_fail_tools.html Baseline Measurements from the Oregon HF - GAP Project Interim Measurements from The Oregon HF-GAP Project