Assembling the Team

At a minimum, team members starting a multidisciplinary HF clinic should consist of:

Executive Sponsor
This person should be a member of the hospital executive who give the clinic the “rubber stamp” of approval and who will advocate on the clinic’s behalf.

Administrative Leader
The administrative lead should have the ability to hire staff, ensure the day-to-day operations are in order, provide support where needed and arrange for appropriate space and resources.

Physician Leader with expertise in HF Care
The Physician should provide clinical leadership as well as active involvement in preparing the protocols and pathways required for good patient care. The Physician should be committed to providing this leadership.

Nurse(s) with skills in heart failure and patient teaching
Within the multidisciplinary model, the Nurse should have extensive cardiac experience, specifically in HFcare. The Nurse should have skills in education and understand the concepts of chronic disease management.The level of nursing support decided upon may vary from clinic to clinic. Some clinics prefer the Nurse Practitioner role, others an expert Registered Nurse and others a hybrid of both roles. This is a decision that needs to be made with the team from the outset. Nurse Practitioners can provide a wider scope of care, whereas the registered nurse can practice with Physician orders. The scope of practice varies between provinces and we recommend that this is ascertained before starting.

Some examples of competencies required of the HF Nurse are:

• Able to provide heart failure self-management teaching and support
• Advanced cardiac assessment skills
• Confidence to introduce the concept of end of life planning
• Safely provide telephone support/advice to patients
• Able to use word processing, email, and spreadsheets on computer

Clerical support
The Clerk should be responsible for making appointments, registering the patients, phoning patients before the clinic, filing, preparing charts for the visit, taking calls, collating lab and test results for checking by the Physician/Nurse Practitioner.

Programs with the following resources should also consider support from the following health care providers:

• Pharmacist
• Dietitian
• Physiotherapist
• Social Worker
• Palliative Care
• Geriatrician
• Palliative Care
• Occupational Therapist

Staffing Levels

It is not easy to determine staffing levels. First, it is important to determine how many patients the clinic may expect. To do this, data around local HF demographics should be sought and a clear care pathway be defined to ensure that once the endpoint is reached that the patient is discharged back to their referring source.

A survey to determine patterns of staffing in heart function clinics across Canada was performed in 2004 (presented at Canadian Cardiovascular Congress, 2004 by Kaan A, Clark C and Edmonds M). Fifteen clinics responded and showed that:

• Most clinics (87%) function using the “Nurse-managed, Physician-directed” model of care. Meaning that the day to day function of the clinic is managed by the Nurse, however the care of patients is directed by the Physician. One clinic was directed by a Nurse Practitioner. As this survey is now 6 years old, this model may have changed somewhat
• 40% of clinics see 10-19 patients per week. There was great variation in the number of patients seen as some clinics were just one session per week and some ran 5 days per week
• On average, clinics see 8 patients per session
• Average caseload of RNs was 136 patients (range 60-200). One Nurse saw 10 to 20 patients per week
• One Clerk manages an average caseload of 50 patients per week
• 25% of nursing time involved clerical duties and data entry, the rest was telephone support, clinic visits and patient education

There must be a commitment to meet regularly to assess staffing levels based on the patient load and whether or not the patients are appropriate for the clinic.

Developing a Clinic Philosophy

The philosophy of the HF clinic should be spelled out early on. What is it that the clinic wants to achieve? This focuses the team and allows for planning of services.

Identifying Key Indicators

It is important to identify what indicators the clinic will measure to determine success and monitor progress. The CHFN recommends the following indicators: symptoms, quality of life, heart function, HF hospitalizations, CV hospitalizations, and survival.

Measuring Outcomes

Membership to the CHFN facilitates access to the National Database. For more information on applying for membership please go to http://www.chfn.ca/how-to-become-a-chfn-site.

Each new centre needs to have:

• A Physician leader of the HF clinic
• A commitment to HF management and follow up
• A Nurse (full or part time) with special expertise and training in HF management
• A sufficient number of HF patients and referral community
• A commitment to enter their patient data into the database with regular downloads to national database
• A willingness to sign a contract of agreement.

We make regular updates to our database to enhance implementation and usefulness. It is expected that you will upload data within 6 months of receiving the database. The CHFN pays a yearly licensing cost on your behalf. If data are not uploaded in 6 months then the summarized National data will not be sent to your centre. If data are not uploaded regularly a reminder will be sent and if no data are uploaded in four consecutive quarters then you would be required to pay the yearly licensing cost in order to remain a Network participant.

The database is designed as a local tool like an electronic medical record but also allows download of data without specific patient identifiers to the National Database. The data that is uploaded is secure and password protected, as the upload technology uses the same encryption technology used for online banking. All patients must sign a consent form before their unidentified data can be entered into the database and uploaded to the national database. There is a consent template located in the members section. Once we have approved and received your signed Program Agreement, you will get a username and password for the website.

Support

What we can give to you is the database to help organize and track your patients locally (you ‘own’ this data), opportunity to benchmark your clinic with the National data, opportunity to ask research questions of your data and that of the National data, use of the data to lobby more effectively for local resources, an invitation to come to our annual meeting currently held in conjunction with the Heart Failure Society of America in September, networking with like minded colleagues to improve the management of HF patients and to learn together, and access to all benefits of the website and the Network.

Team Development

The clinic should meet each month at least to review difficult cases, prepare a plan and to review clinic issues. An agenda should be prepared and action items prepared. Once a year, it is valuable for the team to meet in a “retreat” style to review outcomes, revise the goals and plan for the year. The CHFN database is able to provide centre specific reports that allows a program to track outcomes.

Documentation

Some sample documentation is included that may help with preparing local documentation:

Attachment	Size
Sample Release Form	2.76 KB
Sample Clinic Letter 1	3.56 KB
Sample Clinic Letter 2	34.03 KB
Sample Referral Letter	3.46 KB
Sample Discharge Record	3.81 KB