Integrated Care of Patients with Atrial Fibrillation: Building an AFib Clinic Model

In this interview, we speak with Tara U. Mudd, MSN, APRN, NP-C, EP Nurse Practitioner, about the new Atrial Fibrillation (AFib) Clinic at Norton Heart & Vascular Institute’s Heart Rhythm Center.

Tell us about the EP program at the Norton Heart & Vascular Institute. How many EP procedures are done there annually?

Norton Heart & Vascular Institute is a part of Norton Healthcare based in Louisville, Kentucky. The Heart & Vascular Institute cares for about 250,000 patients per year in Kentucky and Southern Indiana. We have 4 adult-service hospitals in Louisville and 27 outpatient locations in the area. Telecardiology is offered at more than 30 clinical sites in the region. There are 45 board-certified cardiovascular physicians and 30 advanced practice providers (APPs) with expertise in interventional cardiology, structural heart, cardiothoracic surgery, advanced heart failure, vascular surgery, and electrophysiology. We currently have 4 board-certified electrophysiologists, and a fifth will start on November 1st. We also have 4 APPs (3 APRNs and 1 PA-C). With our 4 current electrophysiologists, we do about 500 ablations per year and approximately 1,500 device implants per year. We have a dedicated AFib Nurse Educator as well as a team of device clinicians to manage our extensive device clinic, which has over 6,000 patients enrolled.

How and when did the concept for the new Atrial Fibrillation Clinic come about?

About 3 years ago, Dr. Morris and I began discussing the concept of creating an AFib Clinic. This initially started with a desire to reduce unnecessary admissions from the ED for atrial fibrillation. We felt that the patients we were seeing in follow-up in the office and who were admitted for workup could be treated safely in an outpatient setting. Therefore, we started developing a pilot protocol with our ED physicians; if patients could be triaged quickly and were stable, they could be discharged home for follow-up in the office within 24-48 hours.

We soon realized that there was a need for this type of offering within Norton Community Medical Associates, which has approximately 30 primary care offices across the area. We first identified gaps in access to EP services. For example, there was some confusion as to when to refer to general cardiology versus EP as well as the best workflow to get patients where they need to be, as patients were experiencing prolonged wait times for appointments. We hoped to improve access to care while also getting patients in to see the appropriate experts in AFib management.

In July 2019, Norton Healthcare partnered with us to develop a comprehensive APP-driven AFib Clinic. This has allowed our patients quicker access to guideline-directed AFib care as well as comprehensive resources and education to support them on their health journey.

Who is a part of the AFib Clinic team? Are other subspecialties included as well?

This is an APP-driven AFib Clinic. My electrophysiology APP colleagues and I primarily triage all new referrals to the clinic. However, we have the full support and partnership of all of our electrophysiologists, who will also see patients in the AFib clinic if they require more advanced and invasive therapies. We also refer our patients to other subspecialties such as pulmonary, nutrition, pharmacy, mental health, and endocrinology; but in the first quarter of 2020, we will launch an onsite multidisciplinary AFib Clinic, where patients will be able to see these subspecialties in one location. This will be accomplished by a combination of telehealth visits as well as in-person visits.

How was AFib care historically managed in your hospital setting? Tell us more about the challenges your program had encountered with AFib patients in outpatient follow-up or presenting to the emergency department.

We often found that referrals to the ED for AFib resulted in admissions for testing and workup that could be done in an outpatient setting. This was likely occurring because there was no clear and established guidance for what to do with this patient population. We wanted to provide an efficient and safe pathway for our ED colleagues to quickly triage these patients, and if appropriate, discharge them with rapid follow-up in the AFib Clinic for further management. In our previous workflow, we found that if the patient was admitted, they would often be discharged to follow-up with either primary care or general cardiology, or worse, get lost to follow-up. Our desire was to create a process to capture this patient population and provide them with the best service possible to improve their outcomes.

How important was standardization of atrial fibrillation management across your service line and healthcare system?

A lot of great data has come out in the last few years on effectively managing atrial fibrillation and reducing the risk of complications. Therefore, we wanted to create a culture within our organization that honors that. We also wanted to reduce unnecessary admissions and allow space for patients in the inpatient setting who truly need urgent care. Standardizing our approach allows us to accomplish these goals.

We recently looked at the data on our patients with an implanted device and a >1% AFib burden, and assessed whether or not they were appropriately anticoagulated based on their CHA₂DS₂-VASc score. We found that in over 6,000 patients, the amount of people who should be anticoagulated but weren’t was <0.01%. We credit this to creating standardized workflows, specially trained staff, and screening processes to identify these patients.

What protocols and changes in workflow are now in place?

Our AFib protocol allows our ED providers to rapidly exclude for admission, stabilize, and discharge with rapid (24-48 hour) follow-up in the outpatient AFib Clinic. For our primary and urgent care colleagues, we have created a specific referral order for the AFib clinic. This order goes into a work queue monitored by our AFib Nurse Navigator, who then reaches out directly to the patient and gets them scheduled for follow-up. We have also provided primary and urgent care with a dedicated phone line and email address for our clinic. We are working with our access center for patients who self-refer to the Norton Heart & Vascular Institute, to make sure that the patients who are calling for an AFib-related diagnosis are scheduled appropriately within the AFib Clinic.

At their visit, all patients are screened using an AFib Risk Factor Report Card to determine what further testing and evaluation is needed. We have also adjusted all of our office note templates to automatically include the CHA₂DS₂-VASc score, so that patients are appropriately identified for stroke risk reduction.

How many patients are now treated at the AFib Clinic? Describe the types of services you provide.

Our current model allows us to see approximately 65 patients per week, or about 3500 patients per year. We anticipate this to increase further as we bring on additional MD and APP support within the clinic to meet the demand of the community.

At their initial visit, we discuss risk factors and arrange for further testing as appropriate. We have a lab in our clinic, as well as an onsite nuclear/non-invasive department for echocardiography, nuclear stress testing, Holter monitors, etc. In addition, we have a full device clinic to evaluate any implanted devices or apply other external monitors. We have created a workflow to schedule patients for sleep apnea testing within 1-2 weeks after their visit with us. This includes both home studies and in-lab studies.

As our multidisciplinary clinic is established, we also anticipate onsite dietary/nutrition counseling with licensed nutritionists, medication management with a pharmacist, mental health services by a licensed social worker or mental health APP, and continued support from our sleep medicine colleagues on effective sleep apnea management.

Tell us about your use of a Nurse Navigator.

Initially, our primary goals for our AFib Nurse Navigator were to improve patient education, provide a single point of contact for patients throughout their care, assist in coordinating care with other disciplines, and triage patient concerns surrounding AFib symptoms or related procedures. Currently, the Nurse Navigator’s day-to-day job responsibilities include handling pre-procedure education, calling all patients after their procedures, triaging patient calls, managing the work queue to schedule all ED and primary care referrals, and managing our AFib community support group.

Tell us more about how patient education is managed.

We believe knowledge is power, so we want our patients to have as much evidence-based knowledge as possible. The bulk of the education comes from our team of providers in the AFib Clinic, as well as from our AFib Nurse Navigator. We have created our own patient education materials for AFib, catheter ablation, hybrid surgical ablation, antiarrhythmic medications, and device implantation, and we go over these with patients during appointments. We have found that appropriately educating our patients on the front end reduces the number of triage phone calls, urgent after hours calls, and ED visits regarding their disease state.

Lastly, what would you say are the key elements for creating an AFib care model?

The key elements to our success in creating this care model were having a physician and APP champion, supportive administration, and forward-thinking practice managers. Dr. Kent Morris (physician champion) and myself (APP champion) were responsible for helping to create the framework and clinical needs of the care model, or the “wish list” so to speak! We worked closely with our administrative team to utilize our existing resources to their maximum potential and request additional resources as needed. Once it was time to formalize the pathway, we relied heavily on our practice manager, Melissa Allen, as well as members of our IT support team, to build the Epic workflows, clinic schedules, staff utilization, and scheduling templates.

The management of patients with atrial fibrillation is complex, and the field continues to evolve rapidly as more research is done. As an organization, we are committed to providing the highest standard of care to our patients. At Norton Heart & Vascular Institute, we want to offer a destination center that offers patients the opportunity to be seen by experts in their disease state. The creation of the AFib Clinic was a key component of that mission, and we look forward to providing our patients with the tools they need to live healthier lives. 

Disclosure: Tara U. Mudd, MSN, APRN, NP-C has no conflicts of interest to report regarding the content herein. Outside the submitted work, she reports personal fees as a consultant for AtriCure, Medtronic, and Boston Scientific; she also reports personal fees as part of the speaker bureau for Pfizer and Bristol-Myers Squibb.