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Complex Chronic Diseases: Heart Failure and COPD Clinical Pathways

Cardiovascular Health & Stroke and Respiratory Health SCNTM

What is it?

  • Heart Failure (HF): HF is on the rise in Canada, one in two Canadians is impacted by this growing epidemic. Appropriate HF management, and the support of HF patients in the community, are critical to improve quality of life, keep HF patients at home longer, and reduce hospital readmissions or length of stay in hospital.
  • Chronic Obstructive Pulmonary Disease (COPD): COPD is a common, chronic progressive lung disease. COPD exacerbations, or sudden worsening of COPD symptoms, account for the largest number of preventable hospital admissions compared to all other chronic diseases.
  • HF and COPD have been identified as priorities by AHS Executive Leadership and  the Quality, Safety and Outcomes Improvement Executive Committee (QSO)

Our objective:

To implement evidence-based Heart Failure and COPD clinical pathway care which supports patients as they move from the hospital towards community and primary are.

Our target outcomes:

  • Improve patient experience
  • Enhance consistent care
  • Coordinate acute, community and primary care in order to facilitate smooth transitions throughout the patient health care journey
  • Coordinated care with specialist and primary care physician
  • Reduce length of  hospital stay
  • Reduce readmission rate to hospital and emergency departments

Contact info hfpathway@ahs.ca or copdpathway@ahs.ca

Implementation Tools

Clinical Tools and Resources

HF and COPD Education Talks – “Pathway Pearls” Series

“Pathway Pearls” is an education series aimed at providing information to health care providers regarding the Heart Failure and COPD Order Set Bundles. Each session focuses on a different aspect of the pathways.

Heart Failure and COPD - Innovation Learning Collaborative

Learning Sessions

Learning Session 1 – Nov 28, 2018

  • Leduc, AB
  • Objectives:
    • Increased awareness  of the continuum of care along the COPD and HF clinical pathway (acute, community and primary care)
    • Increased understanding of the purpose and benefits of the ILC
      • Role of the balance scorecard within your unit
      • Role of data, tools, applications, support
    • Start the team dialogue on the development of the balance scorecard

Learning Session 2 – May 1, 2019

  • Leduc, AB
  • Objectives:
    • To provide an opportunity for networking and peer consultation.
    • To support participant learning needs through evidence based educational sessions
    • To identify improvement opportunities through the sharing of successes, learnings, and challenges,  along with team discussions and action plan development
    • To support efforts to enhance transitions in care.