The CFA Perspective

New Rationale for Heart and Vascular Services Integration

Posted by Stan Holland, Director, Heart & Vascular Center, Sentara RMH Medical Center, Harrisonburg, VA, and Richard Clark, CFA

3/9/17 8:00 AM

 

New Rationale for Heart and Vascular Services Integration image.jpgThe integration of Heart and Vascular Services has been an ongoing challenge for the past 15 years or so.  CFA has long promoted the benefits of heart and vascular services alignment, as the advantages far outweigh the time and effort necessary to achieve integration. 

 Now, the inexorable march to true value-based care delivery, coupled with the need for comprehensive and integrated management of patient care that will be demanded by Episodes of Care (EOC) payment models (also see part 2 on EOC and Bundled Pricing), mandates a new focus on Heart and Vascular Service Line integration.  This post examines the issues, approaches, and potential outcomes of successful integration as a proactive solution to the business challenges and care delivery demands facing cardiovascular services providers. 

Background

 In recent years, hospital vascular programs have begun to expand rapidly to address the growing problem of peripheral artery disease (PAD),[i] the availability of new interventional technologies and attractive reimbursement rates.  Vascular disease is a growing problem, affecting 8 to 12 million people in the U.S.  While enticing, the ability of hospitals to take advantage of vascular opportunities has been hindered by many factors:

  • Turf battles between rival specialists (see “Factors Affecting Integration,” below)
  • Personal agendas
  • Historical inattention to the disease
  • Lack of a truly collaborative approach to identifying at-risk patients, intervention and follow-up
  • Lack of physician leadership
  • Lack of appropriate organizational structures to allow for effective program development, business planning and marketing

 

Clinical Basis for Integration

 Technological advances in non-surgical techniques have accelerated the treatment of PAD – specifically, the advent of percutaneous transluminal angioplasty (PTA), vascular stents and various atherectomy devices.  Of note is the fact that while the use of PTCA and coronary stenting has eclipsed cardiac surgery in volume and rate per population for cardiac disease, PTA/stent volumes and rates have also increased along with vascular surgery volumes and rates.  Additionally, technological advances in diagnosing PAD have begun to replace conventional diagnostic angiography and digital subtraction angiography with computed tomographic angiography.  The use of CTA has progressed rapidly, and where available, has almost completely replaced conventional angiography.

 

Factors Affecting Integration 

Desirous of expanding their vascular business, many hospitals have become paralyzed by the political turf war that has erupted between vascular surgeons, interventional radiologists, interventional cardiologists and vascular medicine specialists.  This turf battle has arisen largely due to the development of nonsurgical techniques, including PTA and stents.   Historically, interventional radiologists performed most endovascular procedures, then vascular surgeons entered the field, and interventional cardiologists have been adding this capability, including endovascular training as part of interventional cardiology fellowships.  Many believe that no single specialist has all the skills required to perform all procedures, therefore necessitating a more collaborative, and multispecialty approach to vascular services. 

Interventional cardiologists have become leading advocates of their position in the overall treatment of PAD.  They argue that they are best trained and equipped to manage the disease, have interventional skills (characterized by the philosophy that “a vessel is a vessel”), and access to the cath lab where peripheral interventions can be performed using the same fluoroscopy and angiography equipment.  They also differ from the interventional radiologists in that they are not exclusively dependent upon referrals.  No less important is that PAD cases are promising sources of additional practice revenue providing some protection against shrinking cardiac reimbursement.  (Unfortunately, interventional cardiology training programs that have endovascular training typically do not incorporate comprehensive vascular medicine and vascular patient care into their programs.)

 

Cardiac & Vascular Service Line Integration at Sentara RMH Medical Center (SRMC) 

The ongoing Cardiac and Vascular Services integration at SRMC has resulted in numerous advantages to both the hospital and the involved physician specialists.  At the System level, an overarching structure provides the framework for cardiac and vascular coordination:

 

System Level

Leadership and OrganizationThe CV Service Line Vice President provides administrative leadership to cardiac and vascular, while a Cardiac Service Line Medical Director and Vascular Service Line Medical Director routinely collaborate to ensure a coordinated approach to physician leadership.  There is also a formal structure of System Committees to coordinate the service lines.

(Note:  The Cardiology Service Line committee structure has been in place longer, so it is more complex; it is organized into geographically regions.  The Vascular Service Line committee structure is organized around anatomical structures.)

Information TechnologyThe Cardiovascular Information Technology Plan reflects system-wide consistency.  This is being developed into a system-wide focus across both services.

(Note:  Ten of twelve hospitals are on EPIC EMR.  Two hospitals have come online in 2016.  This has created opportunities for the “new kids on the block” to influence the eight incumbents.)

Quality ManagementThe overall approach to quality includes Data Registries and System Score Cards.

(Note:  The Cardiac Service Line Score Card is more complex, as influenced by the greater number of registries in the Cardiology & Cardiothoracic Service Lines.  Vascular is adding more modules.)

 

Hospital Level ‒ In Place

Leadership and OrganizationThe Heart & Vascular Center Director provides administrative leadership to cardiac and vascular, while unified CTS, Cardiology and Vascular Medical Directors meet regularly to ensure a coordinated approach to physician leadership.

LocationHeart & Vascular Services are located adjacent to one another in the Heart & Vascular Center; Heart & Vascular uses the same Interventional Suite and shares the new Hybrid OR.

Quality ManagementCardiac, CTS and Vascular have score cards; Medical Directors share results, successes and opportunities (i.e., documentation).

(Note:  SRMC has an advantage in that the Data team is located on site within the Heart and Vascular Administrative suite.  Three of the four staff have experience in, or still work in, the clinical lab.  This is a real advantage because they understand workflow.  These staff now report to Corporate data team leadership.  This will expand their understanding assuring consistent methodology.)

Physician & Advanced Practice Clinician (APC)[ii] Recruitment & Cross-trainingThe coordinated service line provides opportunities to participate in the recruitment process as well as exploring the sharing of APCs across disciplines in the future.

Multidisciplinary Clinical Services, Patient Care Models

●      Structural Heart/Hybrid OR – Vascular, Cardiology, Cardiothoracic Surgery

●      Pulmonary Embolus Service – Cardiology, Vascular,

●      Mini-Afib Staged procedure – EP (Cardiology), Cardiothoracic Surgery

●      Laser Lead Extraction (later 2017) – EP (Cardiology), Cardiothoracic Surgery

           

Also at the Hospital level, we are exploring numerous other opportunities for synergy.  Conceptually, this exploration is born out of questions from physicians within the service line asking why are we doing this?  A great question and it must be answered – the why behind the what!

 

Hospital Level - In Development

Leadership Training for PhysiciansExploring options for providing joint leadership training for current and future medical directors together in the same setting.

Accreditation (ICVAL & ICEAL)PVL and Echo Labs are both accredited; looking at leverage opportunities to share the process & Best Practices.

Continuing Education HoursExploring Staff, Physician and APC opportunities to share resources for continuing education.

Interaction with Hospital Credentials CommitteeReview current and new credentials, provide recommendations and jointly develop credentials for new clinical procedures.

Peer Review The integrated service line will provide subject matter experts and develop an understanding of the process.

Succession PlanningJoint effort to develop 1-3-5-year plan for Physicians, APCs and Heart & Vascular Leaders.

ResourcesProvide joint recommendations to the Capital Allocation Committee, 1-2-3 years; review and approve/recommend FTE and Non-Salary Budgets

Operating EfficiencyLeverage Best practices for efficiency and successful documentation of patient acuity and registry and score card metrics.

 

Conclusion

 

For the Hospital and the System, the advantages of an integrated cardiovascular service line are clear from the information provided in the lists above.  For the cardiac and vascular physicians, the advantages of integration are many:

  • The Integrated Service Line’s influence in the Hospital/System is greater than separate service lines (e.g., in the budgeting process, with the Credentials Committee and other Medical Staff Committees, with the C-Suite, etc.).
  • Diagnosis of disease and patient treatment can be enhanced through collegial multidisciplinary approaches.
  • Cross-training and sharing of APCs can mitigate staff shortages.
  • Opportunities for continuing education are enhanced.
  • Practice succession planning and recruitment of physicians and other staff are better organized with greater opportunity for success. 

As you move toward heart and vascular integration in your hospital, and if you encounter resistance from your physicians, these advantages should be presented and explored – they will help your medical staff see a win/win scenario. 

If you are interested in learning more about strategies for heart and vascular integration and/or other programmatic concerns about cardiovascular services, please contact CFA at (949) 443-4005 or by email at cfa@charlesfrancassociates.com. 

[i] PAD is a highly prevalent disorder and a frequent marker for systemic atherosclerosis, thus identifying a group of patients at high risk for cardiovascular mortality and morbidity.  Estimates of prevalence run between 8 and 12 million in the U.S., prevalence increasing with age.  Only half of Americans with PAD are symptomatic.  About 25% of patients presenting with coronary artery disease also have PAD.  Although most common in the extremities, PAD also occurs in the carotid arteries, abdominal aorta and renal arteries.  The risk factors for PAD are essentially those of coronary artery disease, with diabetics at 3-4 times the risk of developing the disease than non-diabetics. 

[ii] Physician Assistants, Nurse Practitioners, etc.

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