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Rethinking Ambulatory Cardiovascular Strategy:  Part Two – Example Approaches

John Meyer, LFACHE

In the previous blog post (refer to Rethinking Ambulatory Cardiovascular Strategy:  Part One – The Big Picture posted on 4/19/18), I discussed the rationale for the need to reconsider your ambulatory strategy.  

From the perspective of the cardiovascular service line administrator, let’s look at example approaches and some real world situations to illustrate these issues.

Example Approaches to Enhancing Ambulatory Strategy

Ambulatory strategy starts at the clinical and operational level.  Here are some examples of areas that can make a direct or an incremental impact on your approach to ambulatory care:

1. Adapt Rapidly to Changing Technology – Options for treating patients on an ambulatory basis are continuously expanding. Be attuned to these changes and move as rapidly as is feasible to adapt and change. Note that the transition period could lead to an unintended consequence – a short-term drop in (inpatient versus outpatient) revenue – but will yield long-term incremental results.

Example:   Creating same-day discharge PCI programs using/expanding transradial arterial access.Transradial access lowers bleeding complication rates; access closure is more reliable with pressure alone (without closure devices); and earlier patient ambulation helps reduce nursing time required per patient.  Research in example hospitals has shown a savings of from $1,200 to $1,900 per case when radial access is used.[1]  Estimates of the use of radial access in the U.S. are currently in the 25% range, with wide variation by geographic location.

Example:   ED-Based Chest Pain Observation Units. Care of the patient presenting to an ED with chest pain and/or angina remains a common yet challenging aspect of emergency medicine.  Acute coronary syndrome typically presents in nonspecific fashion.  The development and evolution of the ED-based observation unit has helped to safely assess and diagnose those most at risk for an adverse cardiac event.  Furthermore, there are several provocative testing modalities to help assess for CAD.  (High Sensitivity troponin screening (HSt) possesses extremely high predictive power to rule in or out acute MI, so this may decrease need for increased space considerations.)

2. Incorporate Best Practice Guidelines. The latest expert consensus documents, incorporating best-practice guidelines, protocols and algorithms, inclusive of their recommendations, should be incorporated into hospital care practices and revised policies and procedures. More specifically, patient risk-assessment/stratification and resultant treatment recommendations, applicable to those patients that can be treated safely and effectively on an ambulatory care basis.

Example:   Case selection criteria for hospitals performing PCI without on-site surgical backup. The SCAI/ACC/AHA Expert Consensus Document – 2014 Update on PCI without On-Site Surgical Backup documents the recommendations for patient selection, treatment and potential transfer.  This assists the attending physician in making clinical decisions, including ultimate judgements about ambulatory versus inpatient versus transfer-out treatment planning.

3. Re-Engineer Care. Re-engineering patterns of care, particularly across the continuum in an episode of care model, is critical to financial success. Integral to this process is the clinical discussion that should take place to evaluate each patient category, apply the most progressive care practices, identify barriers to success and gaps in performance, and make appropriate changes. Inherent in this process is the identification of outpatient treatment opportunities, either through the application of best-practice guidelines and protocols, or locally-derived care practice improvement efforts.

Example:   Many hospitals have successfully re-engineered their heart failure care by assigning case managers and implementing rapid-response to patient follow-up – including telephonic monitoring, cardiac rehab, outpatient clinic visits and other ambulatory approaches.  Particularly applicable to bundles, such programs have successfully decreased inpatient stays, readmissions, ED visits and overall cost per case, while stressing carefully managed ambulatory processes.

Example:   Cardiac rehabilitation programs reduce readmissions and save money, but most patients don’t participate.  Maximizing rehab participation can have a dramatic impact on overall utilization and must be a key part of any ambulatory strategy.  Ensuring that physicians stress its importance and incorporate cardiac rehab referrals for their patients can aid in increasing participation.

4. Enhance Physician Strategy. No ambulatory care strategy is complete without physicians, both PCP’s and cardiovascular specialists. Increasingly, hospitals and health systems are having difficulty recruiting top talent both to staff expanding primary care networks and the CV service-line. Integrating physicians into the organizational and operational infrastructure of the service-line and incentivizing them through appropriate vehicles should inevitably lead to stronger ambulatory approaches, while mitigating potential efforts by physicians to directly compete for ambulatory business with hospitals. Ambulatory hospital-physician integration strategies are structured along a minimalist to maximum continuum: from professional physician services agreements to cover outlying clinics with diverse geographic coverage, to co-management agreements (see example below), to compliant JV outpatient facilities, to employed physician arrangements.

Example:   Simple Integration through Co-Management Agreements.  CV physicians participating in co-management agreements can be legally incentivized to address a specific set of priority goals and objectives, including prioritized ambulatory strategies custom to the organization.  Examples are numerous, such as staffing outreach clinics, developing best-practice protocols/policies and procedures, re-engineering care, lowering cost per procedure, enhancing patient experience, hitting a target percent of outpatient versus inpatient cases, and others.

5. Minimize Leakage. Ambulatory strategy suggests that the hospital needs to capture and retain its fair share of this market. Building utilization by keeping patients within the system results from offering services that are accessible, geographically located and medically appropriate, as well as managing individual care to maximize clinical effectiveness and overall patient care experience.

ExampleCase Managers/Care Coordinators/Nurse Navigators. To prevent leakage, many hospitals have re-engineered care through the use of case managers who are responsible for individual patients throughout the entire episode of care.  They insure patients are linked to appropriate providers, follow-up appointments are scheduled, and patient experience is enhanced.  Additionally, minimizing readmissions through case management has proven to be very successful.

6. Improve Interoperability/Optimize the CVIS. Increasingly, interoperability issues with and between information technology systems are present in ambulatory development – between inpatient and outpatient systems, physician practices, and off-campus facilities – and even within the hospital’s cardiovascular information system (CVIS). Historically, inpatient and outpatient data management have utilized different IT platforms. Increasingly, systems will need to be adapted to monitor and manage patients between facilities – in real time -- throughout an episode of care. At the service-line level, CVIS optimization is a significant problem that can impact all levels of patient care, physician reporting and information generation for ongoing operations management.

Example:  Proprietary Episode of Care Case Management Platforms.  New IT platforms are being designed to facilitate the management of individual cases over a defined episode of care with interoperability between networked facilities and real-time reporting.  Primarily used by case managers, they seek to coordinate inpatient and outpatient utilization to maximize efficiency, effectiveness and overall cost of care.

ExampleOptimization of CVIS.  Most hospitals have invested in state-of-the-art data collection and reporting systems for their cath lab, cardiology and vascular services which offer structured reporting – either with or without cardiovascular picture archiving and communication systems (CPACS).  Many are still dysfunctional.  Optimization projects focus on customizing interfaces with hospital IT systems, structuring and customization of reporting templates for local physicians, and maximizing technology to support existing clinical work flow.  The efficient operation of CVIS can have a dramatic impact on ambulatory work flow.

7. Continue Ambulatory Facility Development. While “right-sizing” facilities for the ambulatory challenge is a big picture issue – and a high priority given budgetary implications – the CV service-line administrator must optimize utilization of existing facilities, while actively participating in the planning of new, expanded/relocated, geographically disparate outpatient capabilities. Additionally, robust planning needs to occur to adapt to new technology and incorporate rigorous risk-stratification/patient selection criteria for all procedures to produce the highest percentage of outpatient-appropriate patients.

ExampleLowest-Cost Setting.  A teaching hospital with a full-service cardiovascular program purchased a rival “heart hospital” near its main campus for use as an ambulatory care and short-term surgical facility.  This facility has a fully-licensed cath lab.  With the goal of utilizing the lowest-cost setting to lower its cost per case, the main hospital’s cath lab manager is attempting to schedule elective diagnostic caths at the other facility to free-up its main cath lab schedule, enhance the patient experience and lower the overall costs of routine scheduled procedures.


As inpatient volumes are impacted by ambulatory strategies, and value-based reimbursement and episode of care models continue to proliferate, hospitals will be challenged to provide appropriate access to care through ambulatory facilities.  Cardiovascular services play a vital role in such strategies through maximizing the appropriate applicability of outpatient-related services, the distribution of services among its geographic market area, and the operation of such services to maximize both physician participation/integration and the overall patient experience.  Service line administrators have a vital role to play in this strategy development.

If you are interested in learning more about ambulatory strategies, bundled pricing, cardiac services strategic development, service expansion or low volume cardiac surgery programs and/or other programmatic needs for cardiovascular or other services, please contact CFA at (949) 443-4005 or by e-mail at


[1] Refer to

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