In this interview, we speak with Anil K. Gehi, MD, FHRS and T. Jennifer Walker, MSN, ANP-BC about creating an atrial fibrillation (AFib) care model at the University of North Carolina. Dr. Gehi is the Director of Cardiac Electrophysiology at UNC Health Care in Chapel Hill, North Carolina. Ms. Walker is a nurse practitioner in the Division of Cardiology at UNC Health Care, and clinical faculty for the UNC School of Nursing.
Tell us about the EP program at UNC.
UNC Health Care is an integrated health care system owned by the state of North Carolina and based in Chapel Hill. UNC Health Care includes the UNC Medical Center in Chapel Hill, the UNC School of Medicine, and eleven affiliate hospitals across the state. UNC Medical Center in Chapel Hill is a 950-bed hospital that includes a five-physician EP department within the division of cardiology. On an annual basis, our EP program performs approximately 500-600 device implants and 700-800 ablations, the most common being AFib ablation (350-400 annually).
How and when did the AFib Care Network model at UNC come about?
The idea for the AFib Care Network model grew out of a need for coordinating atrial fibrillation care in the system. Patients with AFib bounce between the ED, urgent care center, primary care provider, cardiologist, and electrophysiologist. Patients frequently receive competing messages, and care is often not consistent or of high quality. We wanted to consolidate and improve efforts through a more coordinated program. We began the process by putting together a team of key stakeholders who were engaged and committed to developing ideas to solve this problem. Our team first decided to focus on AFib presentations in the ED and the hospital where we could have the most impact. This began with a pilot project in 2015 funded by the UNC Center for Health Innovation. Success of this project led to an opportunity in 2017 for a larger and more comprehensive initiative, which is currently being funded by the Bristol-Myers Squibb Foundation.
How was atrial fibrillation care historically managed in your hospital setting? What challenges had you encountered in outpatient follow-up of atrial fibrillation patients?
When we began investigating the management of AFib in the ED, we found that nearly 90% of patients presenting to the ED at UNC Medical Center were being admitted. Review of these admissions revealed that many patients likely didn’t warrant admission for urgent therapy. However, there was no clear guidance in the ED for best acute management of AFib, including which patients truly warranted admission. In addition, there was no plan for a smooth transition to the outpatient setting. Patients were following up with primary care or cardiology after their hospitalization, but often these appointments were delayed and patients would return to the ED with a repeat episode of AFib. Also, time constraints in the outpatient setting interfered with the ability to provide thorough AFib education, individualized instructions on self-care of AFib, or parameters on when to seek medical attention.
Tell us about the differences between the AFib Care Network, AFib Transitions of Care locations, and the AFib Integrated Care clinic.
The AFib Care Network is the conglomeration of providers across the UNC Health Care system that have received specialized training for AFib management. This includes providers (e.g., NPs, PAs, clinical pharmacists) that have been trained to manage acute atrial fibrillation issues in the AFib Transitions of Care clinics, providers trained to manage chronic comorbidities such as obesity, hypertension, and sleep apnea in the AFib Integrated Care clinic, and primary care providers who have become local experts in overall AFib management. We have four AFib Transitions of Care clinics across the state to serve several of the UNC Health Care system hospitals, and there will be two additional AFib Transitions of Care clinics launching in the next six months. We have one centralized AFib Integrated Care clinic with plans to eventually open other Integrated Care clinics as the need arises.
Why was standardization of atrial fibrillation management important across your service line and healthcare system?
Standardization of management is key to reducing unnecessary utilization of healthcare resources and to improve quality of care. A simple standardization of triage in the ED helped reduce unnecessary hospitalizations for AFib. Educating providers in the AFib Care Network on best practice recommendations for atrial fibrillation has helped reduce variance in care, and we have already demonstrated improved quality metrics such as appropriate use of anticoagulants, screening for atrial fibrillation risk factors, and management of AFib-associated comorbidities.
What opportunities for standardization of patient care were identified? (e.g., ED pathway, AFib order sets, stroke risk assessment, etc.)
We saw several opportunities for standardization. We first focused on the ED by developing a triage plan for the physicians, so that cardiology consultation in the ED was unnecessary and appropriate discharge could be streamlined. In addition, we set a standard for follow-up of AFib patients within 72 hours at an AFib Transitions of Care clinic. This quick access to specialty care has reduced repeat ED visits and hospitalizations. A protocol of care is delivered in the AFib Transitions of Care clinic, including key patient education, stroke risk assessment and prophylaxis with shared decision making, rate and rhythm control as appropriate, and planning for comorbidity management. Care is established and coordinated with the patient’s care team (e.g., primary care, cardiology, and electrophysiology). Protocols were also developed for comorbidity management in the AFib Integrated Care clinic as well as for primary care physicians in the AFib Care Network. These include goals and targets for hypertension management, evaluation and treatment of obstructive sleep apnea, heart failure management, obesity management, and promotion of physical activity.
How is a team care approach utilized? What members take part in the multidisciplinary care of AFib patients, and what other service lines (e.g., nutrition, heart failure, pharmacy, ED, etc.) participate?
We have sought out and integrated key members from multiple specialties to our team. This includes electrophysiologists, cardiologists (including heart failure and hypertension experts), ED physicians, primary care physicians, advanced practice providers (APPs), cardiology pharmacists, endocrinologists, sleep disorder specialists, nutrition and weight management experts, and health system leadership. We have all worked together to develop protocols of care and develop ideas on the best way to integrate new care pathways into the system. Our patients are typically seen by APPs or cardiology pharmacists with supervision by a cardiologist or electrophysiologist, which optimizes the value and utilization of APPs. We believe a multidisciplinary team approach provides the best care to our patients.
How is patient education managed?
Patient education is an integral part of our program, as we strongly believe that patients who learn to self-manage their atrial fibrillation have improved outcomes. Since each patient has a different learning style, we have several strategies to deliver high-quality, individualized education for our patients. We teach them to be proactive by giving them an “action plan,” which includes recognizing AFib symptoms, performing pulse checks, and taking steps to manage each episode. Patients are also given a “treatment plan” that highlights cornerstones of their AFib management plan. Written material includes a comprehensive patient booklet entitled “Living With Atrial Fibrillation,” which encompasses key elements of how to live well with AFib and how to manage risk factors. These important concepts are also discussed at our quarterly AFib patient support groups. Lastly, we offer online educational videos that provide an overview of commonly asked questions and essential AFib education.
What would you say are the key elements for creating an AFib care model?
The critical element to creating a successful AFib care program is having a team of motivated individuals with aligned goals to improve care of atrial fibrillation in the existing healthcare system. Involvement of stakeholders is critical to promote transparency and identify gaps in patient care best served by the multidisciplinary team.
Motivating the stakeholders and understanding their interests helps guide the care model, especially with the transition away from fee-for-service and towards value-based care. Finally, organizational, leadership, and community support is necessary, as coordinating and reorganizing a system of care can be a huge undertaking.
How have you defined success for your team? What outcomes have you seen as a result of the creation of the AFib clinic?
We define success by continuous improvement in our metrics and further expansion of our program. Outcomes such as the total number of AFib ED visits, percentage of ED visits leading to admission, total number of patients referred to our AFib clinic, improved AFib quality metrics (such as anticoagulation use, screening, and treatment for AFib-associated comorbidities), and patient satisfaction are being tracked over time. Positive feedback from community providers and “success” stories from patients also validate the benefits of our program.
Have you also seen cost savings for atrial fibrillation to the healthcare system?
Atrial fibrillation is a tremendous cost burden to the healthcare system. There undoubtedly have been cost savings, as our program specifically aims to reduce unnecessary AFib hospitalizations and ED visits. We will be doing a formal cost savings analysis in the future so that other systems can understand the value of investing in the development of their own AFib care program. Additionally, it is important to optimize delivery of cost-effective care as the U.S. healthcare system transitions towards a value-based care model.
Is there anything else you’d like to add?
We’d like to express our appreciation for all those at the UNC Medical Center, the UNC Center for Health Innovation, and the Bristol-Myers Squibb Foundation who have helped us to develop and expand our program.
Disclosures: Dr. Gehi reports a grant from the Bristol-Myers Squibb Foundation. Outside the submitted work, he reports being on the advisory board at Biosense Webster, and speaker’s honoraria from ZOLL Medical; Dr. Walker reports grants and salary support for research from the Bristol-Myers Squibb Foundation.