Partner Spotlight: KHSC’s Heart Function Clinic
Transforming heart failure care in our community
April 14, 2025.
The Heart Function Clinic at Kingston Health Sciences Centre (KHSC) is redefining heart failure care in Frontenac, Lennox and Addington. As a key partner of the Frontenac, Lennox & Addington Ontario Health Team (FLA OHT), the Clinic plays an essential role in the Integrated Care Pathways that guide care from the very first visit with a primary care provider, to hospital treatment and ongoing community support.
What are Integrated Care Pathways?
Integrated Care Pathways are clear, step-by-step plans that connect various care providers—from primary care and hospitals to specialty clinics, home care, and community paramedics—to deliver seamless, evidence-based care for people with chronic conditions. In the FLA OHT region, these pathways guide a person’s journey from early screening and diagnosis through treatment and follow-up care, ensuring timely testing, reducing long hospital stays, and preventing unnecessary readmissions. The FLA OHT is developing common pathways for conditions like chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) to improve care experiences, boost community health, and keep every care provider connected.
These pathways are a top priority for the FLA OHT because they tackle some of the biggest challenges in our health system. “Significant hospitalization rates for heart failure and chronic obstructive pulmonary disease have been found across the province, and for the FLA region in particular, we see over 1,000 hospitalisations per year for heart failure and COPD, with substantial associated costs and long lengths of stay,” says Dendra, Project Manager with the FLA OHT. By offering a proactive, evidence-based approach that uses both virtual tools and hands-on clinical care, Integrated Care Pathways help people move smoothly from hospital care back into their community, improve disease management, and build a more sustainable, efficient health-care system that enhances overall health outcomes.
Bridging specialized care with community support
The Heart Function Clinic at KHSC is a key partner of the Integrated Care Pathways for managing heart failure in the FLA region. It acts as a central hub where people receive essential services—such as echocardiograms (an ultrasound test that creates images of the heart to check its structure and function), medication adjustments, and post-hospital stabilization—that help kick-start their recovery and long-term management. Once a person is stabilized at the Clinic, their care is seamlessly transferred back to their primary care provider, with additional support provided by programs like Ontario Health atHome or Community Paramedics. This smooth transition ensures that each person receives timely and continuous care.
Key successes and impact
The Clinic has made remarkable progress in improving access to care. By hiring key personnel such as a CHF Physician Assistant and a Nurse Practitioner, the Clinic has increased its capacity by 25 per cent and reduced median wait times from 92 days in Feb 2024 to just 43 days as of February 2025. The CHF Physician Assistant works closely with individuals for up to an hour to explain next steps, and connect them with resources like pulmonary rehabilitation and smoking cessation programs. In addition, remote care monitoring ensures that people can be watched over from the comfort of their own home and receive immediate care if needed.
Through support from the KHSC Cardiac Rehabilitation Program and Echocardiography Lab, primary care providers can now access an expedited echocardiogram service where their high-risk patients can receive an echocardiogram within two weeks of request, which facilitates prompt diagnosis and treatment initiation. This is no small feat - and the Cardiac program’s efforts were recognized in a letter of thanks from Dr. Kim Morrison, Executive Lead of the FLA OHT, together with the Integrated Care Pathway Primary Care Physician Leads Dr. Kevin Loughlin and Dr. Anirudha Garg. The doctors say that the leadership and engagement demonstrated by the Lab will be a model for other providers of the diagnostic testing community.
A key factor in the Clinic’s success is its focus on collaboration. Operational improvements, including a Heart Failure Hotline and an e-consultation service, have given primary care providers quick access to specialist advice, ensuring that high-risk individuals get the care they need swiftly. In addition, remote care monitoring has been made available through the Heart Function Clinic in collaboration with Ontario Health atHome and Community Paramedics programs in the region.
“The enhanced collaboration between care providers in our region is the goal of the Integrated Care Pathway – to defragment the system,” explains Dendra. “Seeing the engagement from primary care partners, community paramedics, home care, and others has been incredibly encouraging and demonstrates the collaborative approach health-care providers have across this region. While it’s still early in our integration work, this collaboration is sure to have huge impacts on people’s health-care journeys.”
Looking ahead: building on success and expanding the network
KHSC, FLA OHT, and our partners are committed to further strengthening the link between specialized heart failure care and Integrated Care Pathways. Future plans include deepening collaboration with community cardiologists and expanding services into rural areas through additional clinics. “This year has been transformative for our region,” Dendra reflects. “Our partners are deeply engaged. We’ve learned that the health-care providers in this region appreciate opportunities to connect and collaborate, and the FLA OHT plans to continue bringing care providers together to establish new ways of working.” With ongoing efforts to reduce wait times and improve follow-up care, the integrated approach is making a real difference in people’s lives across the region.