Along the continuum of cardiac disease, heart failure (HF), with its associated poor outcomes and high utilization of health care resources, has emerged as an area of focus in recent years. There is currently no single entity responsible for ensuring that all parts of HF care (e.g. acute care, community care, performance measurement and monitoring, funding, and others) are considered together and that the cycle of system quality improvement is consistently orchestrated. As such, there is considerable variability and fragmentation of patient care and outcomes in Ontario.
The current and evolving demands associated with a chronic, complex condition like HF, and the challenges in meeting these demands, requires a collaborative partnership approach at the local level (among primary care physicians, specialists, and allied health professionals) and the provincial level (among system agencies).
With an outstanding demonstration of commitment and engagement, 3 Early Adopter Teams across Ontario agreed to take on the Integrating Heart Failure Care Initiative (IHFCI) during 2017-2019, which tested the implementation of a collaborative model of quality HF care delivery.
The materials that follow are the outputs of this effort. Informed by the Early Adopter Teams’ learning and input from clinical and system experts, the Provincial Roadmap for Improving Integrated Heart Failure Care provides guidance and critical considerations to HF care providers and leaders across Ontario on implementing integrated and evidence-based HF care. The Evaluative Report includes detailed descriptions of each Early Adopter Teams’ activities and lessons learned during the initiative. The IHFC Implementation Support Toolkit is a toolkit that includes resources for others interested in integrating heart failure care, and will be revised on an ongoing basis.
In the current landscape, as care teams work towards better connected care in the context of Ontario Health Teams, the learnings from the IHFCI may provide a base from which to integrate care more broadly across a system.