Current State Assessment of Heart Failure Care-Identifying Spokes and HubsThe following survey package is a tool to help create a high-level understanding of heart failure (HF) care provision currently in the (enter sub-region name) and identify the opportunities for integration to advance quality care for adults living with heart failure (HF).

The package contains two different surveys to help identify areas where spoke or hub level care exists in your region.

Survey A. Assessment of heart failure care: SPOKE Survey B. Assessment of heart failure care: HUB

Patients with HF who are low complexity or low risk tend to be monitored within a spoke and therefore primary care could be the target for Survey A distribution.

Patients with HF who are more complex or moderate risk tend to require specialty care and therefore locations where specialty care is provided (e.g. cardiologist, internal medicine) could be the target for Survey B distribution.

Patients with HF who require expert HF care or tertiary care services would require care within a Node. These types of services would be located within a hospital with tertiary cardiac services and would be already identified for your region. Therefore, this package does not include a survey for identifying a node.

Items on each of the surveys are based on the material from the document, Minimum Requirements and Key Clinical Services within a Spoke-Hub-Node Model of Care.

Survey responses will help to:

1. Understand the current management of heart failure care provided by you/ team, across the patients’ illness continuum.

2. Identify the existing relationships, both formal and informal, that you or your team members have with other care providers, in the management of adults living with HF.

3. Recognize the resources and additional expertise you/your team require to enhance the care you provide to adults living with HF.

4. Identify the HF resources or expertise that you or your team possess and are willing to share with other providers to enhance the overall quality of HF care within your region.

Current State Assessment of Heart Failure Care- SPOKE

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Contact Information1. Enter the following information about you/your organization:

Primary Contact NamePosition EmailName of OrganizationAddressCity/townPostal CodePhone numberFax

Clinical Setting Which of the following best describes the setting where you or your program provides care for patients with heart failure? (Check all that apply)

□ Family physician office□ Family Health Team or Community Health Centre□ NP Led Clinic □ Other (please specify)

2

Health care providers2. Do you have nursing or allied health members currently within your practice?

□ No□ Yes. Please indicate the involvement of all the staff (non-physicians) in

your practice setting (Please check all that apply). Team member Onsite- part of

the practice/team

Offsite Through Referral(Access? If yes, where?)

Nurse Practitioner (NP)Registered Nurse (RN)Registered Practical Nurse (RPN)DietitianPharmacistRespiratory TherapistPhysiotherapistPsychologistSocial WorkerOther (please specify)

3. Are there any adult chronic disease programs within your practice? □ No□ Yes. Please indicate the programs that are offered within your

practice? (for example, diabetes, COPD, mental health, geriatrics)

4. Are there chronic disease programs that you do not offer within your practice, but within your community that you can access for your patients?

□ No□ I am not sure□ Yes. Please indicate the programs offered within your community for

chronic disease management support

5. Do you have access to cardiac rehab program in your area? □ No□ Yes

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Clinical care specific to heart failure

6. Please indicate the clinical evaluations performed and level of confidence in your setting for adults with heart failure:

Clinical evaluation for people with heart failure

Please indicate the level of confidence in your setting for providing the following clinical evaluations related to heart failure

Not confident

or resources

not available

Not confident but actively building skill

set

Somewhat confident

Confident

Very confident

Symptom burden (i.e. fatigue, shortness of breath, diminished exercise capacity and fluid retention/weight gain)Functional limitation (i.e. Do you assign NYHA Class?)Cardiovascular risk factors assessmentStatus of comorbid conditions that can impact management of heart failure (e.g. renal function, anemia, COPD)Vital signs, weightVolume Status (e.g. peripheral edema, rales, heart and lung sounds, hepatomegaly, ascites, jugular venous pressure, hepatojugular reflux and postural hypotension)Assessment of a patient’s ability to perform activities of self-management and daily living (e.g. endurance, cognition)

8A. Which heart failure medications are you initiating in your practice setting?

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Medications for

people with heart failure

Please indicate the level of confidence in your practice setting for initiating the following medications in patients with mild heart failure symptoms.

Not confident

Not confident

but actively building skill

set

Somewhat confident

Confident Very confident

DiureticsBeta-Blockers ACE-Inhibitors Angiotensin Receptor Blockers Hydralazine/Nitrate combinationMineralocorticoid Receptor Antagonists DigoxinSacubitril/Valsartan Ivabradine

8B. If you are not initiating any of these evidence-based medications for people with heart failure, what would help improve your confidence for initiating any of these medications in your practice setting?

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9A. What heart failure medications are you titrating to optimal doses in your practice setting?

Medications for people with heart

failure

Please indicate the level of confidence in your practice setting for titrating the following medications in patients with mild heart failure symptoms.

Not confident

Not confident but actively building skill

set

Somewhat confident

Confident Very confident

DiureticsBeta-Blockers ACE-Inhibitors Angiotensin Receptor Blockers Hydralazine/Nitrate combinationMineralocorticoid Receptor Antagonists DigoxinSacubitril/Valsartan Ivabradine

9B. If you are not titrating any of these evidence-based medications, what would help improve your confidence for titrating any of these medications in your practice setting?

6

Patient education and self-care

10.Is patient/family heart failure education provided? □ No □ Yes If yes, what members of your team provide education? (please list)

If yes, what topics are addressed?□ Self-Monitoring and the importance of self-management □ Symptom recognition and action plan for a change□ Medication adherence□ Daily weights□ Salt restriction□ Fluid restriction□ Alcohol restriction□ Physical activity and exercise□ Other (please specify):___________________________

11.What are your main sources for patient education materials? □ Locally developed (e.g. primary care setting, local hospital)□ Heart and stroke foundation □ Internet resources: common internet sites:

□ Other (please indicate)

12.Do you work with patients and families to create a care plan? □ No □ Yes If yes, do you review this care plan at least every 6 months or sooner if required?

o No o Yes

Access to Care

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13. When a patient requires more specialized or advanced care for heart failure

than you/your program can provide (e.g. HF expertise), to whom/where do you refer patients on?

14.Select the statement that best describes your/your program’s ability to provide urgent clinical attention to patients with heart failure who are clinically deteriorating (but not acutely unwell) (select only one): □ Able to provide urgent same-day appointment (Mon-Fri, business

hours)□ Able to provide urgent follow-up appointment within 48 hours□ Not able to provide patients with urgent clinical attention related to HF. □ Other (please describe):

15.In follow up to question #14 above, in most cases, I/we (select all that apply):□ Arrange for direct admission to hospital □ Send patient to Emergency Department□ Refer patient to Heart Failure program/specialist□ Refer patient to Internist□ Refer patient to Cardiologist □ Adjust medications as per clinical best practice guidelines within 24 hours□ Other (please explain): _____________________________________

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16.Please rate access to services for patients in your clinical practice setting.

Diagnostic testing

Poor (not readily accessible)

Satisfactory Good Very good Excellent

12 lead ECGChest X-RayEchoCardiac nuclear testing Cardiac catheterization

Clinical services Poor (not

readily accessible)

Satisfactory

Good Very good Excellent (available within 2 weeks)

InternistCardiologistMultidisciplinary specialized heart failure clinicPalliative care services

17.Do you/your program provide heart failure telemonitoring (check all that apply):□ No, we do not provide this service currently□ Provided completely by program staff□ Provided in collaboration with community partners (please specify

agency/program)□ Other (please specify):

18.Do you/your program provide heart failure home visits (check all that apply): □ No, I/we do not provide this service currently□ Yes, this service is provided by program staff□ Yes, this service is provided in collaboration with community partner

(please specify agency/program)□ Other (please specify):

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Performance measuring and monitoring

19.Are you able to determine how many people in your practice have heart failure?

□ No□ Yes, if so, what is the current number? ______________

20.Do you currently record if your patients have heart failure with reduced (ejection fraction ≤40%) versus preserved ejection fraction (ejection fraction >40%)? If so, how is this recorded?

21. Please indicate if you are able to easily determine what percentage of your HF patients are taking the following medications:

Medication Yes No CommentACE inhibitor or ARBBeta BlockerMRADiuretic

If yes, are you able to provide any additional information about medication regimens for patients with HF ? (e.g. actual dose, contraindications)

22.Please indicate any outcome or process indicators tracked by your family health team related to heart failure. □ Mortality rates□ Re hospitalizations□ Achieved optimal dose of evidenced-based therapy□ Achieved patient goal setting□ Patient quality of life (please indicate tool) _____________________________□ Other (please specify any other indicators tracked)

Wrap Up Questions

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23.What resources or support would enhance your provision of outpatient heart

failure care to patients/family? (please specify)

24.Do you have any resources you are able to share with other health care providers in your region to support patients/family with heart failure? (please specify)

25.Do you have any additional comments overall? (please specify)

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Current State Assessment of Heart Failure Care: HUB

Contact InformationEnter the following information about your HF hub:

Primary Contact NamePosition EmailName of OrganizationAddressCity/townPostal CodePhone numberFax

Clinical Setting 1. Which of the following best describes the setting where you or your HF hub

provides specialized care for patients with heart failure? (check all that apply) □ Community Health Centre□ Specialty practice office□ Hospital outpatient setting □ NP Led Clinic (hospital-based)□ NP Led Clinic (community-based)□ Other (please specify)

Access to care by the hub team2. Select the main source(s) of referral received by your HF hub (check all that

apply):□ Patient self referral□ Hospital inpatient setting□ Emergency department□ Urgent care centre□ Primary care offices□ Specialist offices□ Outpatient specialty disease management clinic (e.g. arrhythmia,

bariatrics, diabetes)□ Other (please specify):

3. Select the source(s) of referral that are accepted by your HF hub (check all that apply):□ Patient self referral

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□ Hospital inpatient setting□ Emergency department□ Urgent care centre□ Primary care offices□ Specialist offices□ Outpatient specialty disease management clinic (e.g. arrhythmia,

bariatrics, diabetes)□ Other (please specify):

4. What are the referral criteria to your HF hub? (please list or attach referral form to survey)

5. What happens to the referrals that are NOT accepted by your HF hub? □ Redirected to another clinic□ Denied and returned to the referring provider□ N/A. We accept all referrals regardless of referral source□ Other (please specify):

6. How many days a week do you/your team see patients in your heart failure program?

□ 1-2□ 3□ 4□ 5□ 5+

7. On those days, what are your hours of operation? (free text)

8. When a patient requires more specialized or advanced care for heart failure than your program can provide (e.g. more HF expertise), to whom/where do you refer patients on?

9. Select the statement that best describes your program’s ability to provide urgent clinical attention to patients with heart failure who are clinically deteriorating (but not acutely unwell) (select only one): □ Able to provide urgent same-day appointment (Mon-Fri, business

hours)□ Able to provide urgent follow-up appointment within 48 hours

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□ Not able to provide patients with urgent clinical attention related to HF. □ Other (please describe):

10.In follow up to question #8 above, in most cases, I/we (select all that apply):□ Arrange for direct admission to hospital □ Send patient to Emergency Department□ Refer patient to Heart Failure program/specialist at node□ Adjust medications as per clinical best practice guidelines within 24 hours□ Other (please explain): _____________________________________

11.Do you/your program provide heart failure telemonitoring (check all that apply):□ No, we do not provide this service currently□ Provided completely by program staff□ Provided in collaboration with community partners (please specify

agency/program)□ Other (please specify):

12.Do you/your program provide heart failure home visits (check all that apply): □ No, I/we do not provide this service currently□ Yes, this service is provided by program staff□ Yes, this service is provided in collaboration with community partner

(please specify agency/program)□ Other (please specify):

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Human Resources

13.The heart failure team is comprised of the following members. (Please check all that apply).

Team member Onsite- part of the team

Offsite Through Referral(Access? If yes, where?)

Cardiologist- heart failure specialistCardiologist- generalistInternistFamily physicianNurse Practitioner (NP)HF training? ❑ Yes ❑ NoRegistered Nurse (RN)HF training? ❑ Yes ❑ NoRegistered Practical Nurse (RPN)DietitianPharmacistRespiratory therapistPalliative care providerPhysiotherapistPsychologistSocial WorkerAdministrative/clerical supportOther (please specify)

14.Do members of your heart failure provide mentorship/guidance for primary care providers/teams?

□ No□ Yes, please describe

15

Clinical Assessment15.Please indicate the clinical evaluations performed and level of confidence in

your setting for adults with heart failure: Clinical evaluation for people

with heart failurePlease indicate the level of confidence in your setting for providing the following clinical evaluations related to heart failure

Not confident

or resources

not available

Not confident but actively building skill

set

Somewhat confident

Confident

Very confident

Symptom burden (i.e. fatigue, shortness of breath, diminished exercise capacity and fluid retention/weight gain)Functional limitation (i.e. Do you assign NYHA Class?)Cardiovascular risk factors assessmentStatus of comorbid conditions that can impact management of heart failure (e.g. renal function, anemia, COPD)Vital signs, weightVolume Status (e.g. peripheral edema, rales, heart and lung sounds, hepatomegaly, ascites, jugular venous pressure, hepatojugular reflux and postural hypotension)Assessment of a patient’s ability to perform activities of self-management and daily living (e.g. endurance, cognition)

16

Medications16A. Which heart failure medications are you initiating in your practice setting?

Medications for people with heart

failure

Please indicate the level of confidence in your practice setting for initiating the following medications in patients with mild heart failure symptoms.

Not confident

Not confident

but actively building skill

set

Somewhat confident

Confident Very confident

DiureticsBeta-Blockers ACE-Inhibitors Angiotensin Receptor Blockers Hydralazine/Nitrate combinationMineralocorticoid Receptor Antagonists DigoxinSacubitril/Valsartan Ivabradine

16B. If you are not initiating any of these evidence-based medications for people with heart failure, what would help improve your confidence for initiating any of these medications in your practice setting?

17

17A. What heart failure medications are you titrating to optimal doses in your practice setting?

Medications for people with heart

failure

Please indicate the level of confidence in your practice setting for titrating the following medications in patients with mild heart failure symptoms.

Not confident

Not confident but actively building skill

set

Somewhat confident

Confident Very confident

DiureticsBeta-Blockers ACE-Inhibitors Angiotensin Receptor Blockers Hydralazine/Nitrate combinationMineralocorticoid Receptor Antagonists DigoxinSacubitril/Valsartan Ivabradine

17B. If you are not titrating any of these evidence-based medications, what would help improve your confidence for titrating any of these medications in your practice setting?

18. Do you/your program provide intravenous diuretics to patients with heart failure (check all that apply):

□ No, we do not provide this service currently □ Yes, provided in program location□ Yes, provided in patient residence location□ Yes, other location (please specify):□

18

Diagnostic testing and interventions

19.Please rate access to services for patients in your clinical practice setting.

Diagnostics and Lab

Poor (not

readily accessible

)

Satisfactory

Good Very good Excellent on site with same day

results

12 lead ECGChest X-RayNaturetic Peptide (BNP or NT-proBNP)Serum electrolytes, renal functionRoutine hematology

Additional diagnostics and

services

Poor (not readily accessible)

Satisfactory

Good Very good

Excellent (available within 2 weeks)

EchoCardiac nuclear testing Cardiac catheterizationCardiac devicesOverall access to more specialized HF care

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Patient education and self-care

20. Is patient/family heart failure education provided? □ No □ Yes If yes, what members of your team provide education? (please list)

If yes, what topics are addressed?□ Self-Monitoring and the importance of self-management □ Symptom recognition and action plan for a change□ Medication adherence□ Daily weights□ Salt restriction□ Fluid restriction□ Alcohol restriction□ Physical activity and exercise□ Other (please specify):___________________________

21.What are your main sources for patient education materials? □ Locally developed (e.g. primary care setting, local hospital)□ Heart and stroke foundation □ Internet resources: common internet sites:

□ Other (please indicate)

22.Do you have access to cardiac rehab program in your area? □ Yes□ No

23.Do you work with patients and families to create a care plan? □ No □ Yes If yes, do you review this care plan at least every 6 months or sooner if required?

o No o Yes

Performance measuring and monitoring

20

24.Do you currently record if your patients have heart failure with reduced

(ejection fraction ≤40%) versus preserved ejection fraction (ejection fraction >40%)? If so, how is this recorded?

25. Please indicate if you are able to easily determine what percentage of your HF patients are taking the following medications:

Medication Yes No CommentACE inhibitor or ARBBeta BlockerMRADiuretic

If yes, are you able to provide any additional information about medication regimens for patients with HF ? (e.g. actual dose, contraindications)

26.Please indicate any outcome or process indicators tracked by your HF hub program□ Number of heart failure referrals□ Wait times (time of referral to assessment by HF hub team)□ Mortality rate□ Hospitalizations□ Achieved optimal dose of evidenced-based therapy□ Achieved patient goal setting□ Patient quality of life (please indicate tool) _____________________________□ Other (please specify any other indicators tracked)

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Wrap Up Questions

27.What resources or support would enhance your provision of outpatient heart failure care to patients/family? (please specify)

28.Do you have any resources you are able to share with other health care providers in your region to support patients/family with heart failure? (please specify)

29.Do you have any additional comments overall? (please specify)

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