The Spoke-Hub-and-Node Model of Integrated Heart Failure Care

• Published in: Canadian journal of cardiology 2018-07, Vol.34 (7), p.863-870
• Main Authors: Huitema, Ashlay A., Harkness, Karen, Heckman, George A., McKelvie, Robert S.
• Format: Article
• Language: English
• ISSN: 0828-282X; 1916-7075
• DOI: 10.1016/j.cjca.2018.04.029

Heart failure (HF) is a significant public health concern. Specialized HF clinics provide the optimal environment to address the complex needs of these patients and improve outcomes. The current and growing population of patients with HF outstrips the ability of these clinics to deliver care. Integrated care is defined as health services that are managed and delivered so that people receive a seamless continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services. This approach requires coordination across different levels and sites of care within and beyond the health sector, according to changing patient needs throughout their lives. The spoke-hub-and-node (SHN) model represents an organization of care that works collaboratively with the primary care sector and is highly integrated with community-based multidisciplinary teams of health care professionals and specialty care. The purpose of this article is to analyze the requirements for successful implementation of SHN models. We consider the respective roles of HF clinics, HF nurse specialists, pharmacists, palliative care teams, telemonitoring, and solo practitioners. We also discuss levels of care delivery and the importance of patient stratification and patient flow. The SHN approach has the potential to build on and improve the chronic care model (CCM) to deliver centralized services to preserve high-quality patient-centred care at affordable costs. L’insuffisance cardiaque (IC) est un problème de santé publique important. Les cliniques spécialisées dans la prise en charge de l’IC offrent un environnement optimal pour répondre aux besoins complexes de ces patients et pour améliorer leurs résultats. La population actuelle et toujours croissante de patients atteints d’IC dépasse la capacité de ces cliniques de prodiguer des soins. On entend par soins intégrés des services de santé qui sont gérés et fournis de manière à ce que les patients reçoivent un continuum sans heurt de services de promotion de la santé, de prévention des maladies, de diagnostic, de traitement, de prise en charge des maladies, de réadaptation et de soins palliatifs. Cette approche nécessite une coordination entre différents paliers et centres de soins tant à l’intérieur qu’à l’extérieur du secteur de la santé, en fonction de l’évolution des besoins du patient tout au long de sa vie. Le modèle en étoile représente une organisation des soins caractérisée par