Partner News | Published: Wednesday, December 16, 2020 4:00 pm
By Marc Toth, Vice President of Cardiovascular Services, Atlas Healthcare Partners and Meredith Banasiak, EDAC, Director of Research, Boulder Associates, Inc.
It is anticipated that by 2030, 82% of all outpatient cardiovascular procedures will appropriate for migration from the hospital to an Ambulatory Surgery Center (ASC)[i]. What will that ASC look like? What should we be building today to be ready for this massive shift? Can we manage a patients’ continuum of care from monitoring and diagnosis to imaging, intervention, recovery and rehab in an ASC?
Since Medicare’s decision to shift PCI to the ASC in January 2020, there has been a dramatic increase and interest in Cardiovascular ASC development. Fueled by the pandemic, and many legislative changes occurring in Certificate of Need (CON) states, most experts agree that these ‘COVID Clean Cardiovascular Centers’ will continue to see rapid growth in the next decade. Whether they are Joint Ventures with Health Systems, independent cardiology groups or multi-specialty ASCs, there are many design considerations that should be evaluated as the type of cardiovascular procedures and other cardiovascular services in the ASC evolve.
A typical standalone Cardiovascular ASC program will include (2) cath labs equipped with fixed imaging, and (1) general CV procedure room which may or may not have a mobile C-Arm. To provide for future flexibility and procedural expansion, the cath lab rooms should be designed in size, function, and location to accommodate future EP ablation and structural heart procedures, based on projected volumes.
These OR-like cath labs are typically designed as stark, sterile environments to support surgical procedures. A new trend is emerging in workplace environments incorporating nature into buildings, known as biophilic design, and is already at work in physician offices and health system public areas. Nature scenes with green walls, potted plants, or moss gardens is a physical signal to people to say that this inside space is safe - research shows the stress-relieving effects of viewing nature[ii]. Viewing nature scenes prior to a stressor alters autonomic activity in the recovery period; this suggests that nature can elicit improvements in the recovery process before and following a stressor[iii].
We envision the cardiovascular ASC of the future designed with pre and post-op recovery, and the cath lab with nature scenes enhanced by digital projections that simulate the natural movement in nature, supplemented by air-filtration systems that produce a cross breeze and germ-killing ultraviolet light. In addition to adding a pleasant aroma in the ASC, Aromatherapy is thought to help reduce anxiety and relieve stress, is practiced in some hospitals and could be used in the Cardiovascular ASC setting.
Offering ambient options in the cath lab can provide a calming wash of engaging color enveloping a room for a positive patient experience. Adding windows and projected ceiling lights or murals can engage the patient and provide a comfortable, calm and tranquil environment. The potential beneficial outcomes include: Reducing physiologic patient stress that often accompanies tachycardia and hypertension to ultimately reduce the need for pain medications and sedatives, and a hemodynamically-stable patient who is awake, yet relaxed, can facilitate throughput within the ASC and the prep-recovery area by requiring less time for observation and recovery from sedation.
Understanding the current and anticipating the future case mix is critical in planning infrastructure like imaging, hemodynamic monitoring, PACs, patient flow, and recovery in the ASC setting[iv]. It is estimated that 80-90% of PCI procedures performed in an ASC setting will eventually be trans-radial because of the very low risk of complications and faster ambulation times. A great concept for convenient and comfortable recovery sure to gain traction in the Cardiovascular ASC model is Airport Sky Lounge[v] recovery room, perfect for recovering radial patients. It was designed and implemented by the Interventional Cardiology team at MedStar Union Memorial Hospital in Baltimore. Creating a recovery area with the creature comforts of an airport sky lounge, and the ability to order coffee and snacks from Uber eats will also aid in anxiety reduction in the ASC.
Cardiovascular ambulatory monitoring devices are enabling a new paradigm of health care by collecting and analyzing long-term data for reliable diagnostics, treatment, and rehab. With the increase in the ever-growing wearables technologies like Apple Watches, Fitbits, and Kardia Mobile, and implants like Implantable Loop Recorders (ILR) and the AngelMed Guardian System, we envision a whole new department in the ASC dedicated to monitoring the patient’s condition(s) called the Smart Heart Department. This department could utilize a patient dashboard model to closely monitor patients' activity, heart rate, and detect dangerous arrhythmias. The Smart Heart department could also incorporate Telehealth and combine with CRM industry partners to become the remote patient monitoring nerve center for cardiovascular patients’ continuum of care.
The switch from episodic care in an ASC to continuous care models will be largely enabled using connected health devices and appropriate digital health software for continuous patient monitoring, recovery, and rehab. All forms of remote monitoring devices need to offer safe, confidential, and reliable tools to enhance the treatment strategy for cardiovascular patients. These technologies can improve costs, outcomes and allow the patient to have more control of their cardiovascular care.
We’ve seen wearables move from the wellness segment to real-time patient monitoring — largely due to advances in Internet of Medical Things (IoMT) technology, the diminishing price of sensors and consumers’ desire to manage their own healthcare. Medical wearables’ benefits come from their ability to collect valuable information; if the provided sensor data is analyzed and acted upon, healthcare professionals can achieve greater transparency in day-to-day operations and improve patient outcomes like smoking cessation and rehab participation. Cardiovascular care is already benefiting from analyzing the data gathered via wearable fitness trackers and implants: Some of the devices allow physicians to track patients’ physical activity and daily calorie intake, and can detect and alert if a patient is having an arrhythmia or heart attack.
Virtual cardiac rehab services can be delivered through a variety of means, including one-on-one phone or video calls between a patient and cardiac rehab professional, or via a hybrid approach that combines center-based services with home-based services. Virtual cardiac rehab app-based platforms like Moving Analytics’ MOVN program are gaining traction, driving a 60% patient participation rate which is much higher than the traditional center-based rehab participation rate of 24%[vi]. The Smart heart department at a cardiovascular ASC could efficiently and effectively manage this important part of a patient’s health journey and free up valuable rehab space in hospital and medical office buildings.
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), partnered with other cardiovascular organizations to jointly release a scientific statement that supports home-based cardiac rehab as an option for some patients based on a growing body of clinical evidence[vii]. The lack of reimbursement is a challenge to adoption, but more research and support of home-based rehab as a safe option could affect payers' decisions moving forward. AACVPR and partners have submitted letters to CMS urging the agency to consider expanding telehealth reimbursement for both cardiac and pulmonary rehab services.
MedAxiom, the nation’s leading consortium of cardiovascular programs, is working to increase engagement in Intensive Cardiac Rehab (ICR) and Virtual Cardiac Rehab (VCR) programs. Joe Sasson, Ph.D., EVP of Ventures at MedAxiom states, “The ASC will become a critical entry point into rehab programs as Cardiovascular ASCs attract an increasing number of patients for procedures in the coming years. Shifting procedures to a lower cost and high-quality place of service cannot just be about the day of the procedure only – it must also function as a directional stop in the patient’s care journey that serves as a conduit for patient wellness post-procedure.”
As Cardiovascular ASC evolves into more than just a site for interventional procedures, the addition of cardiac imaging should be considered and reimbursed as an additional approved service in the ASC. Adding imaging will help provide wrap-around care for cardiovascular patients and prevent patients from having to visit multiple sites for their cardiovascular care.
Although it isn’t currently allowed due to Starke laws, there are many benefits to providing imaging services at a cardiovascular ASC. As cardiovascular imaging continues its evolution from angiograms to Cardiac CT and PET, the logical next step is to have the ASC serve as a single home for patient diagnostics and procedures by including imaging in the ASC setting. This would provide the non-complex patient a single location for services outside of the physician’s office.
We anticipate that rates in the ASC would also be favorable to payers and help lower costs for the healthcare system. As Medicare and private payers continue to shift more complex cases to ASCs, many anticipate more complex PCI and structural heart procedures (e.g., Watchmans and TAVRs) will eventually be performed in the CV ASC. On-site imaging will streamline cardiovascular care by providing more efficient patient flow and scheduling.
In conclusion, even the ASCs we’re building today may not meet the needs to deliver high quality comprehensive cardiovascular care over the next 10-20 years. Having an ASC that covers diagnosis and intervention, as well as ongoing monitoring and delivering virtual cardiac rehab, may seem like a stretch today but helping patients through their cardiovascular health journey will continue to evolve in alternative sites of service like ASCs. We must consider building facilities within today’s cost constraints and health economics models yet constructed in a way that enables easy department additions in the future which may enhance the value of an ASC investment. Understanding your long-term cardiology outmigration strategy is complex and it can take a good partner to help navigate the ever-changing landscape. This is a strategy that may be best deciphered by a team approach.
Atlas Healthcare Partners is an outpatient surgery center management and development company based in Phoenix, AZ with operations in Arizona and Colorado. Atlas currently manages and develops ASCs for Banner Health and is actively expanding into CV-focused ASCs. Atlas views their role as a trusted partner and ASC advisor to their health system and physician partners.
For additional information, visit: https://www.atlashp.com/.
[i] What every health system leader needs to understand about current trends in cardiology, Becker’s ASC Review, September 15, 2020
[ii] Future of Hotel Design, NYT, October 14, 2020, E. Glusac
[iii] Viewing Nature Scenes positively affects recovery of autonomic function following acute-mental stress, Environmental Science & Technology, June 4, 2013 Brown, Barton and Gladwell
[iv] McDonald, T. (2020). Managing the Shift to Elective PCI in the ASC Setting. Cardiac Interventions Today, 14, 1.
[v] Cath Lab Digest: The Radial Lounge, Revisited, March 2018. Nauman Siddiqi, MD, Antony Kaliyadan, MD, John Wang, MD, Interventional Cardiology, MedStar Heart and Vascular Institute, MedStar Union Memorial Hospital, Baltimore, Maryland
[vi] Medtech Intelligence Nov 23, 2020 By Dr. Robert Kowal “Remote Cardiac Monitoring: The Rhythm of Innovation
[vii] How virtual cardiac rehab can fill the Covid-19 treatment gap Advisory Board Blog, April 22, 2020