(CCSP100) INTEGRATED HEART FAILURE CARE ACROSS COMPLEX HEALTH SYSTEMS: EARLY LESSONS FROM THE YEAR 1 IMPLEMENTATION OF THE MID-WEST TORONTO ONTARIO HEALTH TEAM'S DEMONSTRATION PROJECT

Background: Ontario Health’s Congestive Heart Failure-Quality Based Procedure (CHF-QBP) initiative aims to integrate the service delivery model for heart failure patients through Ontario Health Teams (OHTs) with six demonstration sites across the province, including Mid-West Toronto (MWT-OHT). The objectives of the MWT-OHT site are: 1) navigation of equitable care between sites of heart failure patient entry into the healthcare system (six pathways including emergency department diversion, subspecialty and primary care), 2) implementation of technology-enabled care including the Medly remote management program and the Emergency Heart Failure Mortality Risk Grade (EHMRG), and 3) learning from reflections of the multidisciplinary teams, including patient advisors. We report on Year 1 (2022-2023) results across MWT-OHT’s four hospitals and two community health centres.

METHODS AND RESULTS: A comprehensive Measurement and Evaluation Plan assessed objectives 1 (navigation of care) and 2 (technology-enabled care). Indicators were coordinated and collected on a quarterly basis and analyzed using descriptive statistics across a six-month period (October 2022 to March 2023). Objective 3 was assessed through a ‘Lessons Learned’ exercise completed with the project’s Steering Committee (32 members) in April 2023 to reflect on Year 1.

Further to collaborative change management efforts, all pathways were implemented by the end of Year 1. Objective 1: 240 patients have been followed by an integrated care lead with individualized care plans at University Health Network. Optimized referral pathways resulted in seven off-site patients accessing specialized palliative care at Sinai Health. Nine patients accessed primary care through two community health centres. Objective 2: Medly has been implemented across six sites (including primary care) with 228 total enrolled patients. EHMRG scores were recently deployed at University Health Network for 100% of eligible patients, with preliminary results of 83% fidelity to EHMRG recommendations. Objective 3: The ‘Lessons Learned’ results suggest that initiating and sustaining change depended on factors at the individual (e.g., motivation), relationship (e.g., communication), organizational (e.g., leadership), community (e.g., collaboration, project management) and policy (e.g., legal agreements) level.

Conclusion: Early results demonstrate promising impact for integrated patient care and deployment of technology-enabled care across sites. Lessons learned emphasized shared decision-making, aligned goals of improving patient and caregiver experiences, reducing burden of data collection, and coordinating legal agreements. Future directions focus on optimization and scaling of pathways over Year 2. MWT-OHT’s CHF-QBP provides an unparalleled opportunity to inform decisions about integrated funding models for OHTs and strengthen connections across the continuum of heart failure care.