1. Developing a system of care Robert D. Reid University of Ottawa Heart Institute breid@ottawaheart.ca

2. A brief history… “Tickers” Open OP Clinic Add: 0.5 FTE nurse IP program New leader, 1.0 FTE nurse Institutional approach Regional network

3. What changed to allow for dramatic growth in capacity?

4. Success comes from… doing ordinary things extraordinarily well… doing ordinary things extraordinarily well… in a systematic way… in a systematic way… at the right time… at the right time… using effective interventions… using effective interventions… with measured outcomes… with measured outcomes… within a network of care… within a network of care… and a culture of prevention. and a culture of prevention.

5. Intervention Lives SavedNNT Smoking Cessation328,400 9 Lipid Lowering132,777 34 BP Control 63,282 31 ACE Inhibitors (CHF) 11,000N/A ß Blockers (MI) 17,023 120 ASA (MI) 10,365 143 Coumadin (A.Fib) 3,418 2,014 Projected Outcomes of Preventive Interventions

6. Doing ordinary things, extraordinarily well… IMPACT = REACH * EFFECTIVENESS

7. The Untapped National Potential 2,770,128 inpatient hospitalizations in Canada (02/03) If 20% hospitalized pts. smokers = 550,000 patients

8. “I rob banks because that’s where the money is” Willie Sutton

9. In a systematic way… Documentation of smoking status of every patient admitted to University of Ottawa Heart Institute Documentation of smoking status of every patient admitted to University of Ottawa Heart Institute Intervention for every smoker Intervention for every smoker

10. The University of Ottawa Heart Institute In-Patient Smoking Cessation Program > 6500 admissions/year > 6500 admissions/year >1300 smokers identified (20%) >1300 smokers identified (20%) Cessation counseling provided to 90% Cessation counseling provided to 90% An absolute increase of 15% in long term cessation rates An absolute increase of 15% in long term cessation rates 195 new quitters 195 new quitters

11. Prev Med 2003; 36(6):710-20 At the right time

12. Using effective interventions… Brief or intensive counseling Brief or intensive counseling Pharmacotherapy Pharmacotherapy Self-help materials Self-help materials Follow-up contacts Follow-up contacts Interactive voice response (IVR) technology Interactive voice response (IVR) technology Linked to community resources/programs Linked to community resources/programs

13. AskAdviseAssessAssistArrange “A health professional’s advice to stop smoking increases the rate of smoking cessation by approximately 30 percent.” The Power of a Brief Intervention

14. Within a network of care…

15. “A thousand ways to make love but no lovers”

16. With measured outcomes… To demonstrate value for money To demonstrate value for money To provide feedback and motivation To provide feedback and motivation To fine-tune your program To fine-tune your program To benchmark To benchmark …and great stories that bring your program to life

17. A Culture of Prevention Smoking Cessation … single most powerful prevention Intervention in clinical practice

18. Types of influence for change

19. Social influences Champions Champions Culture of prevention Culture of prevention Feedback on performance Feedback on performance

20. Policy influences Smoking cessation as a quality indicator Smoking cessation as a quality indicator Inclusion on care maps Inclusion on care maps Standard orders Standard orders Allocation of human resources Allocation of human resources

21. Organizational influences Documentation of smoking status (a vital sign) Documentation of smoking status (a vital sign) Staff training Staff training Availability of self-help materials Availability of self-help materials Availability of pharmacotherapy Availability of pharmacotherapy Follow-up Follow-up Data tracking Data tracking Links to community resources Links to community resources Provincial quit line Provincial quit line Referral to tobacco cessation specialists Referral to tobacco cessation specialists

22. Checklist Policy  Quality indicator?  Care map(s)?  Standard orders?  Designated people? Organization  Documentation?  Training?  Self-help materials?  Pharmacotherapy?  Follow-up?  Data management?  Links? Social  Champion?  Culture of prevention?  Feedback?

23. Success comes from… doing ordinary things extraordinarily well… doing ordinary things extraordinarily well… in a systematic way… in a systematic way… at the right time… at the right time… using effective interventions… using effective interventions… with measured outcomes… with measured outcomes… within a network of care… within a network of care… and a culture of prevention. and a culture of prevention.