Structural Heart Program Staffing Considerations- Effective Models for Clinic, Procedure and Post Procedure Care

Transcription

1 Structural Heart Program Staffing Considerations- Effective Models for Clinic, Procedure and Post Procedure Care Deborah Campbell Inova Fairfax Medical Campus Edwards Healthcare Leadership Series September 15, 2017

2 Disclaimer Please Note: The information provided is the experience of Inova Fairfax Medical Campus, and Edwards Lifesciences has not independently evaluated these data. Outcomes are dependent upon a number of facility and surgeon factors which are outside Edwards control. These data should not be considered promises or guarantees by Edwards that the outcomes presented here will be achieved by an individual facility. Deborah Campbell is a paid consultant to Edwards Lifesciences

3 Inova Fairfax Medical Campus 855 Beds Separate Cardiovascular, Women s and Children s Hospitals Multi-organ Transplant Program VAD program accredited by TJC Level one trauma Center

4 Initial Program Assessment- July 2014 No separate program identity or space One non exempt RN working out an office in a diagnostics department- no clinical exam space Part time administrative support-patient data entry into cardiovascular database Registry and Research support from separate department Clinical documentation done on paper. Not using Epic EMR

5 Initial Program Assessment-July 2014 Physicians seeing patients in own offices due to lack of space in the hospital No attention to key metrics such as efficiency of work-up, length of stay, cost Poor patient experience Physicians unhappy and demanding change

6 TAVR Program Development Attack Plan Create a separate department new cost center new operating budget including FTE s Identify and build out new space 2 exam rooms Small waiting room 3 staff work areas

7 TAVR Program Development Attack Plan Implement Epic Ambulatory Clinical documentation Registration Scheduling Create Valve Clinic Coordinator job description Exempt position

8 TAVR Program Development Attack Plan Implement patient tracking tool/referral database Create and implement Valve Clinic physician participation agreements Allowed non employed physicians to see patients in the hospital based clinic* Based on experienced level and mandated time commitment to the clinic *Credentialed by INOVA

9 Putting it all together January 2015 Dedicated space in the hospital with small dedicated staff in appropriate job codes Ability to provide multidisciplinary care in a single location Electronic documentation

10 Next Challenges Supporting internalization of outpatient physician practice into the hospital based clinic Maintain volume Evaluate cost and reimbursement opportunities

11 TAVR Volumes and Staffing Add commercial cases 1.0 RN Moved into Valve Clinic space October Added 0.8 RN VCC and 0.6 admin (total 2.4 FTE s) 30 Research only- one PT RN No admin Jun-17

12 TAVR Volumes and Staffing Moved into Valve Clinic space October Added 0.8 RN VCC and 0.6 admin (total 2.4 FTE s) Completed full transition of MD office visits to clinic. Added 0.6 NP and increased PT RN VCC and Admin to FT by fall 2015 (total 3.6 FTE s) Research only- one PT RN No admin Add commercial cases 1.0 RN Jun-17

13 TAVR Volumes and Staffing Added 1.0 RN VCC, 1.0 Admin/Financial Coordinator and 1.0 NP (total 6.6 FTE s) Research only- one PT RN No admin support Add commercial cases 1.0 RN Moved into Valve Clinic space October Added 0.8 RN VCC and 0.6 admin (total 2.4 FTE s) Completed full transition of MD office visits to clinic. Added 0.6 NP and increased PT RN VCC and Admin to FT by fall 2015 (total 3.6 FTE s) Jun-17

14 TAVR Volumes and Staffing Added 1.0 RN VCC, 1.0 Admin/Financial Coordinator and 1.0 NP (total 6.6 FTE s) Added 1.0 NP and 1.0 Admin (total FTE s 8.6) Research only- one PT RN No admin support Add commercial cases 1.0 RN Moved into Valve Clinic space October Added 0.8 RN VCC and 0.6 admin (total 2.4 FTE s) Completed full transition of MD office visits to clinic. Added 0.6 NP and increased PT RN VCC and Admin to FT by fall 2015 (total 3.6 FTE s) Jun-17

15 2017 Staffing and Volume Projections 2.6 Nurse Practitioners 3 RN Valve Clinic Coordinators 2 Administrative Support Staff/Schedulers 1 Financial Coordinator/ Scheduler TVT Registry Support and Research Coordinators supported by Research and Outcomes departments 2017 TAVR volume projection: 250

16 TAVR Evaluation Demographics Preferences/limit ations 1 st visit scheduled with initial contact Records reviewed and scheduling Day 1 Carotids, PFT s CXR/EKG RN assessment and teaching (KC QOL, Frailty,5m walk) NP Assess/H&P IC/Surgeon 1 Day 2 CTAchest/abd/pelvis Surgeon 2 Additional patient specific testing

17 Strategies to optimize referral to OR Outsourcing of medical records retrieval- EHealth Global New patient appointment scheduled with first patient contact Block scheduling for PFT s, Echo and Carotids Block scheduling for physicians with any patient, any doc approach Weekly clinic staff meeting- review of each patient and eval progress NP support for physician consults Real time escalation to leadership of any barriers to throughput Add second OR day

18 Median days referral to OR Jan-June 2017

19 It takes a village.but who s doing what? Valve Clinic Coordinator (VCC) RN with cardiac care experience Participate in all visits (consults, and f/u) Complete nursing assessments including nursing history, symptom assessment, medication history and reconciliation Complete patient education TAVR eval screens-kc QOL, Frailty, 5 meter walk test Resource to schedulers for questions, problem solving Compiles and reviews all diagnostic testing and labs Coordinates with pre surgical testing services as needed

20 Team Roles Valve Program Nurse Practitioner Comprehensive review of patient records at referral Assessment of any prior testing/diagnostics STS score determination at consult and following eval Full H&P Support consults for IC and surgeons Review of all evaluation testing and diagnostics

21 Team Roles Valve Program Nurse Practitioner Facilitates the weekly patient review and procedural planning meeting Inpatient consults as needed Post operative clinic visits

22 Team Roles Administrative Support Referral and intake process- patient s first impression of the program Appointment scheduling (consults, 3-5 day post op, 30 day and 1 year appointments) Requests medical records Reviews Epic for any applicable records Assesses patient preferences and coordinates scheduling of all diagnostic tests for eval and follow ups OR scheduling Patient registration Upload CT s to vendor websites

23 Team Roles-almost done! Financial Coordinator Cross trained for all administrative support roles Performs pre authorization/precertification as needed for TAVR procedure, diagnostics or follow up testing for patients with commercial insurance (primary or secondary)

24 Inpatient Flow Cardiovascular OR PACU Cardiovascular Step down

25 Inpatient Management

26 Inpatient Management Patients admitted to CV surgery service Post op rounding by CV surgeons and PA s Patient s discharged by CV surgery PA service Oversight of discharge disposition by clinic staff to avoid unnecessary home health referrals that may trigger PACT penalties

27 Multidisciplinary Care Planning Weekly clinic staff patient review Weekly patient selection and procedural planning Monthly quality/m&m Discuss evals in progress Review completed evals and CT s Event/data review and discussion Evaluation mgt and planning Access and valve size PI and quality assessment

28 If I knew then what I know now I would have. Better managed referring physician communication Referring physician communication protocol 1. VM message and/or letter to referring physician at time of first patient contact with first appointment date specified 2. Letter to referring physician following committee presentation with outcome and procedure date 3. Phone call to referring physician by a physician following a decision not to accept a patient for a structural heart procedure 4. Phone call to referring physician but a physician immediately following the structural heart procedure

29 Referring physician communication protocol 5. Phone call or VM message at discharge 6. Letter with progress notes and all evaluation testing at 3-5 day follow up. 7. Progress notes/testing from 30 day and 1 year follow visits 8. Phone call to referring physician when a patient is readmitted for complication

30 Program Goals Develop Structural Heart inpatient rounding service Grow Mitraclip program Internalize Watchman LAAC program

31 My Team

32 Thank you

33 Questions?

34 Please see the important safety information at the speaker podium Edwards and Edwards Lifesciences are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners. PP--US-2330 v1.0