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Transforming Heart Failure Care Within the HPA-OHT One Beat at a Time

by Kim Van Wyk (HPA-OHT Project Coordinator) and Katherine Perkins (HPA-OHT System Integration Planner)

Heart failure is a major public health concern impacting millions of people and communities globally. The Huron Perth & Area Ontario Health Team (HPA-OHT) is challenged with an aging demographic, strained health human resources, rural geography, and patients with increasingly complex chronic health conditions. Patients with heart failure have been identified as a priority population with opportunities to improve care integration, provide the right care at the right time and involve patients as partners in their care. The number of individuals in Huron Perth who have heart failure is growing with the increasing average age of our citizens. Patients with heart failure are cared for by many sectors throughout their patient journey, making integration and streamlined care an opportunity to improve access and care quality through community and OHT member co-design.


In 2021, the Huron Perth and Area Ontario Health Team identified the need for an integrated, optimized and people-centred heart failure treatment model to better serve patients living with heart failure. To achieve this, the HPA-OHT collaborated with its member organizations, the HPA-OHT Heart Failure Working Group, Patient and Family Advisors and Middlesex London OHT to implement the Spoke-Hub-Node (SHN) model of integrated care for heart failure. The SHN model is a community-initiated integrated disease management structure in primary care practices that standardizes connections to an established network of community care partners and ensures that a streamlined navigation process for accessing specialist support exists. At the heart of our program are our Primary Care teams, with the central hub being our Internal Medicine team based at Stratford General Hospital and connecting to London Cardiac Care as a vital node. This model has provided the opportunity to transform healthcare access and break down barriers commonly seen between Primary Care and Specialist Care sectors.


Over the past four years, there has been a notable trend in heart failure admissions and emergency department visits within our healthcare system.

  • 30-day HF All-Cause readmission rate 2019-23 shows consistent decline (20% to 13%)
  • ED visits per 100 HF patients has consistent decline 2019-23 (11.6% to 9.2%) despite rural ER previously supporting urgent HF care access in communities.
  • Total HF admissions 2019-23 shows consistent decline (326 to 265) despite a rise in this attributed population over the time period, and despite an observed rise in admissions between 2020 and 2023 for all cause non-HF admissions.
  • HF admissions/100 HF patients 2019-23 reduced 6% to 6.8% is lower than the provincial average despite older population and evidence of poor outcomes in rural regions.
  • Balancing measure of Home & Community Care Support Services (HCCSS) utilization for this HF population shows a reduction in utilization of these services with the implementation of SHN model. (Previous evidence in literature suggested an increased use of HCCSS for this population relative to non-HF patients)
  • Best Care case managers have increased 2019-2024 (0 to 7 therapists) providing care in 9 Family Health Teams and 2 Family Health Organizations
  • Family Health Team Nurse Practitioners providing integrated care at Hub increased 2019 – 2024 (0-5 NPs)

These trends reflect ongoing efforts to enhance heart failure care and support within our healthcare system.


The Spoke-Hub-Node model of integrated heart failure care within the HPA-OHT has streamlined care for patients while improving access and flow to heart failure services within Huron and Perth.

The heart failure program is focused on providing the education and knowledge needed for improving heart failure care to providers and patients.

The program’s next steps are to utilize funding provided by Ontario Health to continue with the SHN model of integrated care, evaluation, improvement, and sustainability planning.

Dive Even Deeper

To learn more about the intricacies and the broader impact of our heart failure care strategies, we invite you to visit the new Heart Failure section of our website. This dedicated space offers deeper insights into the methods, results, and patient stories that highlight the effectiveness of the Spoke-Hub-Node model. Whether you are a healthcare provider, a patient, or a caregiver, you’ll find valuable resources and detailed information to help understand how these innovations are making a real difference in the community.