A Focus on the CV Team: Innovative Programs and Improved Outcomes

In episode 15 of the CardiOhio Podcast, we focus on the role of the cardiovascular team to create innovative programs, and improve patient access and outcomes. We are joined by Andrea Robinson, CNP at OhioHealth and current CV Team liaison for the Ohio ACC Chapter, as well as Kelly Bartsch, PharmD, a Specialty Practice Pharmacist at The Ohio State University.  We discussed several innovative programs led by the CV team, including a unique walk in ambulatory clinic for atrial fibrillation.

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Please subscribe to receive updated episodes automatically! Visit https://www.ohioacc.org/cardiohio-podcast/.

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Transcript

0:08

So welcome back to the Cardio High Podcast. We have a very special topic today. We're gonna be focusing on the cardiovascular team. We'd like to talk a little bit about using the c v team members to extend cardiac care, help improve outcomes, increase patient satisfaction as well. I have the pleasure of introducing a couple of guests who are pretty well known. I think to our Ohio listeners, they're both C B T members that have been involved in the Ohio. Chapter quite a bit recently. First, I'd like to introduce from here in Columbus Andrea Robinson, who's actually the current liaison for our Ohio chapter for the cardiovascular team council. Andrea, welcome. Thanks, Kenny. It's a pleasure to be here and I am excited to talk about this opportunity with cv, team liaison and leadership. Thank you. Yeah, welcome. And then I'd also like to introduce Kelly Barsch Kelly's a PharmD also here in Columbus at the Ohio State University. She's a clinical pharmacist and works very closely in the cardiovascular division there. And she is the chair elect incoming chair of our CB team Council here in Ohio. Kelly, welcome. Thanks, Kenny. Looking forward to our conversation. Yeah. So maybe we can start Andrew with you. I really wanted to get you on because I know, of course, you, you have a background in electrophysiology and you've been working in EP for several years here in Columbus. And I've had a, the good fortune to work closely with you here at Ohio Health. You know, quite a few years ago now, I think it's been several that you and your colleagues proposed. A walk-in clinic for atrial fibrillation, and I really want our members to learn a little bit more about how that clinic was visualized and conceived and, and how it's worked. Obviously, we're all clinicians on the front line and deal with atrial fibrillation on a daily basis, inpatient, outpatient, and all kinds of settings. But what, what was really the rationale that led to considering this type of clinic versus a traditional way we deliver cardiac care? Sure. So I think, you know, I think it, it really was multifactorial. I think number one, you know, our initial focus was really on. Trying to visualize how we could provide better access to patients with atrial fibrillation. You know, as we know with our aging and increasingly comorbid population the number of patients diagnosed with AFib is far outpacing the broadband of cardiologists or specifically electrophysiologists. And, you know, I think with the wealth of data coming out in the last 10 years on, you know, earlier access to rhythm based care showing improvement in outcomes and better cost of care, we really needed to find a way to get these patients plugged in at the right time to the right provider. I think secondarily to that, we've also recognized that AFib is a really complex disease and it usually takes more than just a, a quick conversation to really dig in and educate the patient on all treatment options. Talk about risk factor modification and really get them engaged in their care. And so we wanted to be able to offer a clinical model that would maybe address some of those constraints. So, And third thing I think is, as, as one of the advanced practice providers, we, we really wanted to increase our value to the electrophysiology team. And I, we saw that we could really help fill that gap, that using our advanced practice providers to really be the, the forefront of this clinical model. We could really sort of Offload our physician counterparts to you know, see different types of patients or remain in the lab doing interventions. And we could really help take on, you know, the forefront of treating patients with AFib. So obviously we know these patients are everywhere, right? They're in the emergency room, they're in the hospital service. They, they come to our clinics for new referrals. Were you focusing on a specific subset of AF patients when you conceive of the clinic, and then how did that lead to the actual structure of the clinic that you've created? Yeah, so initially ours and, other, folks across the country that have used this model focus on the patients coming in through the er. it's really widely accepted that a lot of patients with low risk AFib are. Probably unnecessarily admitted to the hospital just because truly there's no better place to offer them quick access to care. And so path of least resistance is to hospitalize them. What we found is that, average length of stay is two to four days for these patients. Really just to get some face-to-face time with an arrhythmia specialist, maybe some imaging and a cardioversion. So on the inpatient side, I think that's where we really saw the need. When we saw a lot of these patients coming in and we thought, we could, we could offer something. Just as good if not much better in an outpatient setting to be able to lower cost of care and increase patient satisfaction. So yes, initially we focused on the acute patients. So we started off with some emergency department protocols, helping those colleagues basically. Evaluate patients and determine if they're appropriate for outpatient care. Really focusing on, you know, what are the risk factors would they be able to be rate controlled in an acute fashion anticoagulated, and then our approach would be to see them within two business days in our clinic. We also kind of rolled out that acute algorithm to even our own practice with cardiology and EP and as well as primary care. So, previously patients may, call their cardiologist or call their primary care and. Report an acute episode of AFib, or it's incidentally found, and they would be sent to the ER with these acute protocols. Patients would instead bypass the ER altogether and come directly to our clinic. Yeah. So I think that's a pretty aggressive goal, you know, to take patients who would otherwise been admitted into the hospital and try to see them. A 24 to 48 hour basis, have you been able to accomplish that turnaround that you intended? And maybe just talk a little bit about the logistics of the clinic in terms of where it's located and who staffs it, et cetera. Yeah, so, so we have, and that, that's been a really big priority of ours. when we, I. Initially met with, the emergency department providers, they let us know that, they were a little bit, a little bit hesitant to adopt this this model of care. they had been burned in the past by, a lot of people come to the ERs and say, follow this protocol, discharge our patients, and. Really there weren't good safety nets in place to see the patients acutely so patients would bounce back to the er. So we really made it our goal to ensure that, you know, every patient referred would be seen within two business days. If it's for an acute episode, so, That's a metric that we follow very closely. we're five years into this now. We look at that, we look at that metric, pretty much continuously. And if we're ever starting to fall above that line of two business days, we've been able to really quickly react, adjust our access, whether it's adding more appointment times or another clinician to be able to be seen up in clinic. The providers that we have in clinic, we use advanced practice providers. it really is a team-based care model. We, we rely on our clinic nurses as well to help triage a lot of the patients over the phone to help decide when they need to come in and if they need to come in prepared for a cardioversion if they need to, come in fasting with a driver in anticipation of that. The apps then do the majority of the clinical visit making, decisions about, rate versus rhythm control, anticoagulation strategies and the imaging or testing needed. And, we're always collaborating with our physicians, so, they're not necessarily coming up and meeting these patients face to face. But, the big part of our, the goal of our clinic is, Not to have these patients followed longitudinally by our clinic. So if they're coming in for the first time, either with a new episode of AFib or just someone referred later on in their, in their diagnosis, but they've never seen a, a cardiology Clinician or then sort of making the decision should they, or do they need to be established with ep and if so, they'll then, see them several weeks after follow up. Some of these folks may be more appropriate to follow with clinical cardiology and some are even, okay to follow with their primary care. So, you know, we do make sure everyone's tucked into someone for follow up in the most appropriate fashion for them. Yeah. So obviously having referred many patients there, I can vouch for the the, the, the increase in efficiency and help that you give all of our general cardiologists and other referring providers. I know obviously, I, I assume most patients, you're starting with maybe their antiarrhythmics or maybe just even an initial cardioversion with imaging. Are there some patients though that you're would consider taking straight to more, invasive. Like potentially ablation and other things, or is it more of a stepwise kind of approach? I mean, it's, you know, in increasingly there there's been more data coming out showing early rhythm control, whether it's with an antiarrhythmic drug or catheter ablation, and certain patients is superior to weight control. And other, you know, other literature even suggests that, you know, catheter ablation can be more beneficial than an antirrhythmic drug. And a subset of population of patients. So we really look at everyone. Individually, you know, and, I think, you know, I think one thing that makes our clinic work is we do follow kind of standardized protocols, but, we're, we're, we're still looking at every patient and the characteristics about them pretty uniquely. It's also a shared decision making interaction with, with every clinic visit. And I think that's part of what The biggest benefit to these, you know, this atrial fibrillation clinic model is that. You know, previously we had seen patients, you know, referred pretty, pretty late in their diagnosis and you know, they may be persistent AFib or longstanding persistent. They'd be referred to EP and you know, they maybe have never even heard that ablation is an option for them. And so I. We're really working to try and see these patients early on in the diagnosis and really just start with really good education about all treatment options and really helping them understand the difference between rate and rhythm control and the risks and benefits of choosing each strategy. And from there, you know, patients have the knowledge to sort of, you know, take a, a larger role in the, in their shared, in their decision making and participate in their care and help make those decisions too. Yeah. And you mentioned education. I think, you know, one thing we see when patients are admitted with an acute episode of af, there's not often a lot of time to address a lot of the comorbidity and contributing factors. And of course, we all know that AF tends to cluster with so many other conditions. You know, hypertension, sleep apnea, in sedentary lifestyle, et cetera. Do you try to address some of those things as well with the patients since you're in a little bit different scenario than say, when we're doing an inpatient consultation? Yeah, a absolutely. And so that's something else that we've sort of hardwired into every visit. So, you know, it's a hospital-based clinic. We sort of pulled it out from our general clinical setting. So we could really, design our appointment slots based off of what the need of the patient was. Not necessarily just trying to fill a template. So we have 50 minute visits to really allow for that education. So everyone gets a good conversation. They fill out their own chats, VAs score. We talk about anticoagulation, we talk about rate and rhythm control. But then, you know, we do carve out time each visit to make sure we go through and we identify all of the risk factors for atrial fibrillation. We, you know, we calculate their BMIs. We look at, whether their blood pressure's at goal. We screen for sleep apnea, we talk about alcohol. And then based off of the findings, we then help come up with an individual plan on whether they need to be referred for a sleep study. we'll involve their, you know, primary care if we need further assistance with, getting their cholesterol or their blood pressure to goal. And then we actually do, we, we follow up with our patients as well, pretty well, so, We, have certain metrics when we wanna refer patients to weight management or sleep management. And then that's where the nurses really come in. we know that that's sort of a sensitive topic to talk about with patients. And so our nurses do a really good job of doing a follow-up call several weeks later to really ask and say, Hey, you know, the referral was put in for sleep. Or, wait, have you been able to, think about it. Did you make the decision to go ahead and proceed and, you know sign up for, a weight loss program and. I think that's what, you know, that it's also a nice benefit of our clinic is that it's a smaller cohort than, than we follow. So, you know, our nurses and our apps are really engaged with this population. The patients feel very safe to talk about these things, and so I think that's where we've really been able to see some success and getting patients closer to their goals for risk factor modification. Yeah. Well, thanks, you certainly, you and the rest of your, your team deserve to be commended for you know, creating a new program that didn't exist and meeting a. What are some of the future goals, you know, for the clinic and are there still some challenges you're trying to overcome as you try to grow this and, and care for this growing, you know, patient population? Yeah, I mean, so it's, it's always been evolving, you know, as I mentioned it, it really was in the beginning. Focused on the acute patients and keeping them outta the hospital and the er. And then it slowly evolved to, now we also have a really big focus on trying to get patients in after their first diagnosis of AFib, sort of becoming like the front door to our EP practice. And that's, that's gonna require, if, if we're gonna continue to fulfill that with this growing population, it's gonna require, you know, probably expanding the clinic a little bit to be able to meet the needs as, as that population is growing. We also wanna be able to offer patients care, close to home. our, our hospital system spreads out pretty over, a pretty diverse geographical range. So, there's some, that We have a second. We have a second. Location already within Columbus, but there's gonna be some considerations of probably expanding in the future as well. Great. We look definitely look forward to hearing more about this project as it grows. And I assume if some of our listeners and their various institutions want to get more information from you about, the clinic in terms of logistics of how you set it up and so forth, I, I assume you'd be okay if they reach out to you? I, I absolutely would, and I, I, I'd encourage it, you know, I would say that, you know, we. I think one of the things we, we took on in the beginning was making sure we collected a lot of baseline data and then data along the way. And so five years in, we have a lot of good you know, numbers showing that we have decreased cost of care, we've got more patients adhering to in a coagulation and more patients on appropriate therapy. So we're happy to share that if institutions are looking to say, how do we make a business case to get resources for that. Well, great thanks Andrea for sharing that information and educating us a little bit as well. And also thanks for serving the state chapter as chair for the last couple years. We look forward to your future contributions as well. Thanks. So Kelly, as a clinical pharmacist, I want to continue the theme of using the entire CV team to help, extend and expedite cardiac care. I know I've talked to you before about some of the programs you've worked on at Ohio State. Mm-hmm. To try to extend care as well. I mean, obviously for many years there's been a pretty critical role for pharmacists in cardiac care given, you know, the complex. Pharmacology we use, but I, I thought I'd just get your input about some new programs that you've been working on that kind of emphasize the role of the clinical pharmacist. Could you just start by kind of describing your current role at O S U and, and what led you to an interest in, in. Cardiac care specifically cardiac. Sure. So I have been at O S U now for a decade and, and when I started we were purely cardiology. So I came on board knowing I was gonna do some anti-coag some antiarrhythmic med monitoring, which is a little bit different than the clinic set up that Andrea's got. And then also Sublimate clinic as well. And through the years myself I work with a fantastic team of a bunch of pharmacists. We've expanded into a lot of other areas of cardiology, so we have a smoking cessation clinic a transition of care clinic a heart failure clinic really, and it just continues to grow as the, the cardiologists identify areas where we can help streamline access and education and making sure patients are staying compliant for their meds. Yeah, I think lipids are one area where, of course, you know, we rely heavily on. On, on cardiac medications and mm-hmm. Especially some new and very evolving set of medicines. So what are some of the things you're doing there in the lipid clinic to help the, the clinicians extend their care to the patients? Yeah, so we have three physicians that are part of our. Our clinic across the system and then a total of eight pharmacists across those clinics as well. So new patients typically come in to see the physician and the pharmacist as a tandem visit and then follow up patients unless they need to see that same physician for cardiology care as well. Follow actually with the pharmacist and just see the, the physician every couple of years, which we're able to do under a collaborative practice that we have set up with the, the cardiology practice at Ohio State. So it really allows. The, the docs to see more of the new patients and help with that initial plan and goal setting, and then us to help kind of execute that along the way without backlog their clinic with all the return patients. How did you kind of set up a collaborative arrangement, in which You know you, you're not just providing information, but actually helping, assist with, with, with the care of the outpatients that you're seeing. Yeah. So fortunately I actually came into that setting, so there were a few pharmacists that had started before me and, and started that process. I. Actually, I think with our, an anticoagulation clinic and got the collaborative practice in place there. So it's, it's kind of just become the expectation when we start new clinics that there will be a collaborative practice in, in place that allows us to manage to a certain extent. We also have clinical protocols for every clinic that really outline what. Is within our scope. And what's, what's outside of that. And certainly the laws for pharmacists in the state of Ohio and Ohio is actually pretty progressive for the practice of pharmacy. So we do have the the fortunate circumstance of being able to do a bit more than our colleagues in other states where we're able to help a little bit more with some of the ordering and referrals and things like that. Yeah, that's great. I know you wanted to talk a little bit about smoking cessation as well. That's obviously a tremendous need. We have clinically and we're often understaffed or not really well staffed to, provide. Tobacco counseling to the patients that really need it. So what areas are you working in there to help address that need? Yeah, so that was a, a clinic that I started actually with one of our residents several years ago. And it's something that if, if other locations you know, other practice sites are looking to start clinics with pharmacy or that are, are education driven or, or have such. Specific medication needs. Especially if you have pharmacy trainees. Typically a lot of those trainees are interested in starting clinics and learning how to do that and being involved in that. But it's less of a, a dollars ask upfront to kind of get that off the ground and pilot it and see if it's, it's gonna work. So the clinic started that way and it's really expanded since then. It's set up now that practitioners from cardiology, as well as several other disciplines, have their own kind of branch of, of smoking cessation can refer patients over or patients can self-refer through the patient portal or just by calling in. To, to schedule an appointment with us. But really the goal is we have a lot more time than what our physicians usually have in practice or in clinic to spend digging into the habits of why people are smoking, you know, what their level of dependence is, what they've tried before, what. What might be good options? And unfortunately a lot of times coverage is an issue as well, so it's also taking the time to make sure we can get these covered at a cost that's less than what they would spend for a pack of cigarettes to make it a, an appealing cost option as well to make that quit attempt. Yeah, that sounds great. Certainly a unmet need. So it's great to have some more resources there. So, I know, I know at our institution anyways, we, so many of the cardiac subspecialties do utilize the pharmacist in different ways. For example, I know in ep, here with, they have a big role with drug monitoring, really doing. You're basically overtaking a lot of the drug monitoring, office visits for some of the antiarrhythmics. So do you also, within your overall team, kind of subspecialize in a few of these different areas in terms of each pharmacist since there's such a varied area within cardiology where, where you can be utilized. Yeah. So Antiarrhythmic Meds, as I mentioned, is, is a, a clinic that I started in when I started at O O S U and it's still one that I staff occasionally. But yeah, exactly as you said, we do a lot of the med monitoring. So especially, with, with Sotalol, Tikosyn, amiodarone, there's such a prescriptive plan for monitoring that needs to happen. So it's nice that we're able to see the patients, get them in at locations oftentimes a bit closer to them. And also just take care of those and connect them quickly to EP if they need it, without the electrophysiologist needing to have those on their schedule. Or even the NPS who are doing now so many more acute things just to. Alleviate some of the burden off their schedule to get those more routine visits done and then connect patients to those resources as needed. Well, that's great. I think we, we'd love to hear more about some of these programs in more detail as we grow through some of these topics on future podcasts. And congratulations you know, as the incoming liaison for the Ohio a c c Cardiovascular Team Council. We look forward to your contributions in the next couple of years. Thanks. I'm gonna try my best to live up to the standard that Andrea started. Yeah, so Andrea I obviously we, of course, in our state chapter we have nurses, we have advanced practice providers, PAs, pharmacists. Do you want to just maybe take a minute and just remind us about the, the CV Team Council in terms of its makeup and maybe highlight a couple things that you've worked on in the last the last couple years and maybe some future goals too. Yeah, so certainly, it's, I, I think you just, you know, went through and named the majority of our membership advanced practice providers, nurses, pharmacists different, whether it's, it can be a cath lab tech or a rad tech. And you know, really I think the focus the last several years has been, sort of making sure that there's. Relevant topics to a non-physician member that are always at the forefront. And I think not just from the, within Ohio a, c, c, but the national A c C as well. You know, I feel like that has been a big focus of this team-based care model. And even, even more so within the Ohio chapter, you know, I just from, your leadership and, you know, Gwen and everyone else's leadership, I think we've really felt valued as a team member. And, you don't always get that within an, a big society like this. Some of the things over the past couple of years we've done is, held. A couple of, sessions on, you know, different clinical topics where you can share best practices and learn about different topics that you may not be familiar with. We had a session about, you know, kind of demystifying how do you maybe create a re start, a research project or put together a case report and then turn that in to either something for publication or a poster to be presented at a regional or local conference. And I will make a plug for upcoming, prior to our. Fall meeting, we're gonna plan to have a CV team happy hour just to get together and kind of meet one another.'cause it's also just been a really great way to network, not just within your own city, but really across Ohio with different, you know, advanced practice and allied health providers either within your specialty or within a different specialty. And really kind of open up some of the pathways to, you know, learn and grow from each other. And goals for the future? I, I have a, I have a a lot of optimism that, Kelly comes with a lot of great clinical and leadership experience already. And so I know she's just gonna continue to, probably look at some of the things that we've done previously and also bring new ideas into the future with how we can just continue to make this a place or place to kind of cultivate education and engagement and networking. Well, that sounds exciting. I just want to thank you both for taking some time to talk about the programs at your institutions and also the council itself. I also want to put in a quick plug myself for our next podcast episode. You know, we obviously, we got some great insight about the c v team today, and we're actually gonna flip to the electrophysiology perspective. And we have a couple outstanding and well-known EP docs from Central Ohio. Ralph Augustin from Ohio State. Anisha mean, who's the chief of VP at Ohio Health, and they're gonna talk a little bit more about the electrophysiologist perspective for both AFib and some other arrhythmias as well. So hopefully you'll be on the lookout for that next episode. But thank you both for joining in and hopefully some of our members will be reaching out to you to learn a little bit more about these programs. Thanks, Kenny. This has, this has been fun. Yeah. Agreed. Thanks so much and, and please do feel free to reach out to Andrea or I if, if we don't know the answer, we've well positioned to get you connected to somebody who does. Okay. Well thanks to our audience as well for joining in this episode of the Card. How podcast? Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,