The Link Between Protocol–Driven Clinics and Growth
News | Published: Friday, June 17, 2016 7:00 am
An Emerging Care Delivery Model that Promotes the Quadruple Aim
By: Anne Beekman, RN, Vice President, MedAxiom Consulting & Ginger Biesbrock, PA-C, MPH, MPAS, AACC, Vice President, MedAxiom Consulting
As health care moves from a fee-for-service reimbursement environment to a more value-based approach, there is increased accountability for providing the right care at the right time. Although, at an individual level, most think that the current structure is patient-centric, there is often a miss around access, compressed care and a holistic approach in the management of these patients. A prime example of the inability to provide this level of care is the atrial fibrillation
(A-fib) patient, who may have a very different course of care dependent upon where care is initially sought. There are high variations in ED management, acute care management, and even primary care management. Some patients may make it to cardiology, where they may or may not receive access to aggressive therapies. Literature shows that many patients are under-treated for stroke prophylaxis, while others are over-treated with hospital admissions, and still others do not make it to the EP physician in time for an effective ablation strategy (Steill, 2011).
An emerging delivery model that has been developed to address these challenges is the protocol-driven clinic. Objectives that need to be met by these clinical programs include:
• Optimal access, which, at times, requires same-day access
• Guideline-driven care, which is an evidence-based, holistic approach by those who are experts
• Appropriate resources for specific patient populations
• Population management at a disease-specific level
Putting a program together that can meet all of these objectives and remain scalable is the key to clinically-effective programs. In answer to meeting these objectives, the protocol- driven clinics have been developed in areas of heart failure, A-fib, hypertrophic cardiomyopathy, and several others; the foundation of these clinics is the team-based care model.
A team-based care model institutes a clinical care team for a given patient population, consisting of health professionals with the training and skills needed to provide high-quality, coordinated care specific to the patient’s clinical need and circumstances (Doherty, 2013). The team is typically made up of physicians, advanced practice providers (APPs), RNs, clinical pharmacists, medical social workers, and others required for a particular patient population. The advantages of the care team approach for the patient are improved patient coordination, care integration and efficiency. For those on the team, the advantages include increased professional satisfaction, an ability to provide proactive care, and the allowance of providers to focus on areas of expertise. Finally, for the health care system, the advantages include efficient care delivery, maximization of resources and facilities (often meaning a lower cost care model), and continuous quality facilitation.
Considerations for developing an effective team-based care model include:
• Creating a culture that engages physicians to participate and collaborate through a physician leader role
• Accepting evidence-based care guidelines as the basis for the clinical pathway or protocols
• Adoption of best practices as standard work
• The make-up of the team, for determining how to best coordinate work and allow all staff to work at the top of licensure/certificate
• Employment of continuous process improvement with
engaged informatics, finance, operations, patient experience and clinical quality team support
Finally, the success of the care team and improved patient care should be central to each decision or process step; all politics and personal agendas should be excluded from discussions and decisions.
A Protocol-Driven Clinic Model
An A-fib clinic provides a great example of how a protocol-driven clinic that can support and encourage growth. The incidence of A-fib is rising exponentially. There will be no shortage of A-fib patients to care for, and the more accessible the program, the more of the local market it will capture. Also, A-fib is a non-life threatening condition, which can create significant co–morbidities if not treated appropriately. The treatment requires rhythm management and stroke prevention measures, which take a great deal of time and patient education to manage appropriately. Anytime we can shift this level of care away from primary care and the ED, it is a ‘win-win’ for all. (See Figure 1)
Key to the development of the right approach is understanding the objectives required for appropriate care. For an outpatient A-fib clinic, the following objectives are necessary:
- Access, with availability within 72 hours of initial referral
- Referral strategy for ED patients, primary care, device clinic and other internal cardiology referrals
- Prompt evaluation for both new onset A-fib and exacerbations of existing arrhythmia
- Evidence-based, protocol-driven intake process with the use of team-based care (APPs, RNs, MAs) to assure access and guideline-driven care (intake to include diagnostics, stroke prevention and short term management decisions)
- Physician oversight for team and direct patient care for management and therapy decisions will be required. The
goal is that the patient will be seen by the cardiologist at the second visit and is well-educated with appropriate diagnostics performed to allow for optimal management decisions to be made
- Clinic is patient-centered, with easy access for appointments, questions and intense patient education for
The program starts with the development of a standard protocol, which should be created by the physician leaders utilizing evidence-based guidelines. The example shown utilizes an NP with strong competencies in A-fib management, in a part–time role. The requirement for this program was 20 patients per week, on average. Figures 2 and 3 show the ROI for a full year, including basic office diagnostics.
Additional value of this program includes downstream revenue from imaging and procedures. There is also a major opportunity for value by freeing up physician time that would have initially been utilized for these visits, allowing the physicians to see the same patients and have more information to make appropriate decisions. This offers a degree of compressed care to the traditional approach. Finally, the use of this clinic to promote easy, early access to the referral base will be priceless in encouraging growth.
A-fib clinics are not the only example of protocol-driven clinics. Heart failure clinics are also becoming more common and have demonstrated great results. More recently, we have seen the development of hypertrophic cardiomyopathy clinics, cardio-oncology clinics, chronic total occlusion clinics, and structural heart clinics, to name few. The resources and protocols may look different, but they all start with a high-performing team and the development of an organization-based protocol or pathway of care. These delivery models truly promote the quadruple aim of high–quality care, cost-effectiveness, patient experience and provider satisfaction. This requires an investment, but the pay-off is invaluable.
- Stiell, Ian, Catherine Clement, Robert Brison, Brian Rowe, Bjug Borgundvaag. Variation in Management of Recent-Onset Atrial Fibrillation and Flutter among Academic Hospital Emergency Departments. Annals of Emergency Medicine. 57.1 (2011): 13-21. Web. 23 Sept. 2015.
- Doherty, Crowley. Principles of Supporting Dynamic Clinical Care Team: An American College of Physicians Position Paper. Nov. 3, 2013.