What motivated you to implement a multidisciplinary model of care at Blacktown Hospital?
Western Sydney has become a hotbed for cardiovascular diseases, in particular heart failure (HF). And we see that in our hospital systems whereby these patients with HF have sort of crept into the acute services of the hospital. It has put a large strain on our hospital logistics and our hospital resources. With this surge of patients who are unwell, we are not able to cater the appropriate level of care for these patients, and then these patients end up with poorer outcomes.
I knew that the model that we came up with needed to be a model that could do, that could rise to the challenge of big numbers while catering to the complexity of the disease process and individualize to different patients. The Australian American and European guidelines recommend multidisciplinary care with the highest level of evidence, but unfortunately, the reality of it is that the uptake of this model has never been all that great, and this is purely related to logistics, staffing as well as the complexity of managing a team in this way. We felt that, you know, the multidisciplinary model of care was a model of care that could cater to the complexity of the disease and also overcome the barriers that we would need to overcome to optimize treatment.
While our treatments have improved significantly, there remains a significant, I guess, barrier. They can be patient barriers, such as an inability to accept the diagnosis of HF or understand it. It can be, you know, physician-related barriers such as time, inability to create enough consultations to speak with the patients or see the patients, and sometimes even inertia with treatment, just because with medication changes we have to be confident and we do not want to cause harm. So I guess with all of this in mind, that’s why we gravitated towards the multidisciplinary model of care because we felt that this was the best way that we could tackle this challenge of HF in this generation.
Please describe the multidisciplinary care model implemented at Blacktown Hospital’s HF Multidisciplinary clinic.
Well, I think the overarching goal of the multi-disciplinary model was to provide individualized care; meeting not only the needs of the disease but the needs of the patients. And to do that, what we ended up doing was putting a team together. And this team consisted of not just, doctors and nurses, but also allied health from multiple different streams of specialties such as pharmacists, social workers, and physiotherapists. And together this team would be reviewing patients simultaneously, and each of us would have our own respective roles, but at the end of the day, the patient would be at the center of the model and we would cater the treatment, not only in terms of medications, but the way that we dose the medications, deliver these medications specific to the particular individual.
So to give you guys a good example, I think, you know, if a patient was to come to our HF clinics, they first start off by seeing myself and my HF doctors and nurses, and we go through a comprehensive assessment looking at the patient’s history. We look at the patient’s living context, their functional capacity and medications. Any changes that we make towards the medications will then be transferred over to our clinical pharmacist, whom the patients will see next. The clinical pharmacists will go through some medication reconciliation, making sure that the doses of the medications are appropriate, that these patients will have an appropriate delivery of the medications so that they can take it, and also provide education on their medications. And while this is happening, if let’s just say we need a little bit more time to coordinate with the local chemists to ensure that the medications are ready to go, these patients after they’ve gone through the assessment, they have a bit of relaxation time, they speak to the nurses and/or the social workers. And this is where we identify any social barriers that could come in the way of implementation of therapy. And if we do identify any of those, we put a plan in place to tackle that issue as well. For instance, if finances have become a bit of a problem, the social worker would then sort of link this patient up with specific support programs for them to afford these medications. At times, we’ve also reached out to non-governmental agencies to help us subsidize the medications for these patients.
The process is actually a lot faster than you think because, you know, initially at the conception of the model, it took a little bit of time, but once the model started running, it became a smooth-flowing service. The patients would then be linked up appropriately. The chemists would have their medications ready, and as they exit the clinic, they would then head towards their local chemist to pick up their medications, and then we schedule them for a follow-up after that. So that’s what a day in our clinic sort of feels like. And like I said, initially it would take a little bit more time. Maybe each patient would need about 30 to 40 minutes. But these days, once they are embedded into the program, it’s a smooth transition. They only need about 20, 30 minutes. And because we know them so well, we’re able to connect with them almost immediately.The multidisciplinary model of care has been running since its conception back in around November of 2021. And the, the great news is that it still continued to run in this fashion up until now with good results.
What was the role/clinical utility of NT-proBNP in this multidisciplinary model?
So the NT-proBNP, I think it’s an excellent tool that helps us in our day-to-day care of our patients with HF. I think initially when NT-proBNP was first introduced to clinical practice, we used it predominantly as a tiebreaker to help us diagnose uncertain situations, such as a patient with breathlessness: Is it related to HF or is it related to lung disease? Now I think moving forward, when we started the multidisciplinary model of care, we started using NT-proBNP very regularly. And I have found that actually it is a great tool for us to evaluate our progress with treatment. It is a great tool for us to monitor compliance as well. And I think overall it’s also a good prognostic marker. It tells us if something is going to happen before it actually takes place. We find that using the NT-proBNP in this fashion has given us a lot more clinical impact. We routinely test for NT-proBNP after optimization of treatment, and then we use it with each subsequent visits for us to see how the disease is responding to treatments. We started using NT-proBNP before the publication of the STRONG-HF study. And so with the publication of the STRONG-HF study, it was very good to see that, you know, this was something that I think even the international community started doing and it was very effective.
What key outcomes were observed after implementing the multidisciplinary care model?
Prior to the establishment of this multidisciplinary model of care, we weren’t doing too well in Western Sydney in regards to HF metrics. We had a readmission rate that was in excess of about 23 to 25% with the state average being around 17%. We also had longer than average bed stays sometimes in excess of almost four weeks as opposed to the average of about seven days. Following establishment of this service, we have seen dramatic improvements in all aspects. Initially when we proposed the model, we weren’t actually aiming too high. We actually thought that we would reduce readmission rates by about 5%. That was our initial, I guess you could say pilot model. But very pleasing to see was that we were able to reduce our readmission rates from about 23% down to 11%, which was a great achievement for us. Our length of stays have actually halved and that’s been very good. We now have an average length of stay of about five to seven days, which is excellent. We have also seen dramatic improvements in terms of survival. And at last tally, we have seen our mortality rates for HF now only in the excess of about 5 to 6% as opposed to previously when it was in excess or about 15%. With the introduction of the multidisciplinary model, what was also good to see was that a lot of patients living with HF now have an improved understanding of the condition. So we now see a lot of people managing their decompensations themselves at home. They know what to do, they know who to call, and they are able to understand what their medications are for. And that’s actually a very, very good thing for us to sort of see as doctors as well. Overall, I think when we look at it from an institution point of view, you know, we look at prevention of rehospitalization and the cost associated with it. We were able to demonstrate, I guess cost earnings of up to about AUD 300,000, and we avoided penalties of about AUD 200,000, and that was just in a three month pilot program. We have since now sort of extended the program into a permanent service. So the numbers in itself are probably a lot more than that too.
What challenges did you encounter when implementing the MDT care model? How did your team overcome them?
There were many, many challenges.I think the top two challenges would actually be in terms of funding and convincing the powers that be about the effectiveness of this model of care. When I was training, HF never had a great outcome. With this multidisciplinary model of care, I guess one of the things that I wanted to showcase was how effective it was to improve outcomes. It was hard in the beginning just because I think convincing people to fund the program is always, never an easy thing, but we managed to do it. And since then, I think, you know, it has been a great thing for us. It has made life a lot easier for us as well as made life better for our patients. And yes, I think for anyone out there who’s thinking of starting a service, just know that sometimes it takes you more than one or two meetings to convince people to, you know, adopt this multidisciplinary model of care. And I hope that the results that we have can actually help you in this regard. I think another challenge is actually managing a team. This is not something that doctors are trained to do. We are trained to learn the disease, you know, to dissect it down to its core elements, to treat it. Managing a team is always something that I think you learn as you mature in this field. But yes, it was certainly a new experience for myself, but I think, again, an advice to anyone out there is that, you know, managing a team is not simple, but it is so important because the team is your greatest resource.
Based on your experience, what are the top 3 advice you have for other APAC clinicians on implementing MDT care models for HF management?
I think if I could give any advice… Well, on top of looking after your team, I think, when starting a service be practical, not perfect. All you need is the core elements to start the wheel moving and perfection can come later on. It is not necessary in the beginning. Another piece of advice is really patience and perseverance. I think in our line of work that is always in short quantities because of the nature of the stress of our work, I guess. But I think when implementing a service, you know, you have to approach it in this way. Like I said, it’s not an easy feat. It took me weeks and months of convincing of negotiations to be able to set the pilot up. And I think that, you know, if you have a pilot that’s successful, it can mean all the difference because you then have results that you can showcase to push the model further on. When we started the model of care, my goal was to improve how we deliver care in our area. But the success of the model has been overwhelming. And now, you know, I guess reaching out to a lot of my colleagues, we see the model now being adopted in Victoria, in Adelaide. They are still in their starting phases at the moment. They’re going through the same challenges that I went through. But I think what was really good to see was that, I think the message actually got across, and that there are now champions for this model of care, and that hopefully soon we’ll see it being adopted widely across Australia. And I think that it will actually sort of validate what we do. It will also improve outcomes for a lot of patients living with HF.
