Disclosures I have no disclosures.

1. The Utilization of Cardiovascular Health Care Teams to Provide High Quality and Valuable Patient Care Amy Winiger RN, MSN, ACNP-BC, AACC ACC North Carolina State Cardiovascular Team Liaison

2. Disclosures • I have no disclosures.

3. Objectives • Discuss the evolution of health care teams driven by supply and demand. • Demonstrate improved quality of care and value of care that advanced care providers bring to health care team. • Discuss efforts by ACC to participate in payment reform for advanced care providers as teams evolve.

4. Team approach • Formative years spent in Indiana • Played recreational and select girl’s soccer team • Learned to appreciate individual’s talent utilized to achieve greater goal • All member’s skillset respected & valued

5. Team Based Approach

6. Individual’s contribution to team

7. Atrium Health Team

8. Team Based Care

9. ACC Workforce Team Based Care • 2003 ACC Board of Trustees new membership Cardiovascular Care Associate (CCA) Diverse interprofessional team registered nurses (RNs),clinical specialists, nurse practitioners (NPs), physician assistants(PAs), pharmacists, CV technologists & sonographers • Advanced Care Providers (ACPs) PAs +NPs

10. Patient centered CV team American Journal of Cardiology

11. ACC Workforce cont’d • Demand/Supply issue w/ clinicians & educators aging workforce • Patients older, sicker, more complex care • Primary care shortages, increasing subspecialization • Additional 3,000 to 4,000 general cardiologists needed • Complexity & time demands American Journal of Cardiology

12. ACC Transformation of Care Initiatives • Study of 7 health care teams structured w/ characteristics high performing teams 1 • Teams evolve response to health care payments • ACPs bill Medicare 85% physician rate • Value of team based care American Journal of Cardiology 1 https://www.the -hospitalist.org/hospitalist/article/125958/health-policy/medicare-billing-regulations-nonphysician-providers-vary2

13. 2015 ACC Policy Statement TBC

14. Literature on team based care • Integrated, TBC can improve measures of -quality of care -lower rates of some measures of acute care utilization -lower medical payments “cost avoidance” 1 • Team approach required to address complex patient needsimproved outcomes patients with cardiogenic shock 2 • NPs added to 5 inpatient care team Vanderbilt 3 • Decrease costs • LOS: Trauma Step down 2.5 to 2.2 days Trauma 7.2 to 6.4 days - Costs: Per case $9,000 (6mil pesos) difference previous 2 years • JAMA • Journal of ACC • Journal of Nursing Administration

16. History Nurse Practitioner (NP) • Co-Founded in 1965 by Dr. Loretta Ford Assistant Professor of Nursing and Dr. Henry Silver 1 • Pediatric Nurse Practitioner Program University of Colorado “envisioned gap of health care access” known for “silver pearls" 1 Journal of Issues in Nursing 2.Journal of Pediatric Health Care

17. Nurse Practitioner cont’d • “Collaborative, collegial relationships with physicians, not physician substitutes” Loretta Ford 1 • Committee recommended national certification, 1974 1st certification 1 • American Nurse Acts: professional nurse may perform additional acts included special training recognized by medical and nursing professions 1 • 28 years later… Yale Journal of Regulation, Institute of Medicine (2010) 2 • Advanced Practice Nurses (APNs) work at full extent of training, timely, efficient, cost effective care to people of United States. • 2 year Program, FNP or AGACNP Family Nurse Practitioner (FNP) treat all ages Adult Gerontology Acute Care Nurse Practitioner (AGACNP) inpatient 1 ANA, American Nurses Association 2 Institute of Medicine • 1. Journal of Issues in Nursing

18. Licensing of NPs • Licensed by the State • A NP shall be held accountable by both the state Medical Board and Nursing Board • Certification by one of the following national credentialing bodies 1.American Nurses Credentialing Center (ANCC). 2. American Academy of Nurse Practitioners (AANP). 3. American Association of Critical Care Nurses Certification(AACN). 4. National Certification Corporation of the Obstetric Gynecological Neonatal Nursing Specialites (NCC). 5. Pediatric Nursing Certification Board (PNCB). www.ncbon.org

19. History of Physician Assistant (PA) • Founder Dr. Eugene Stead Duke University 1 • Creative solution physician shortage, educated w/ medical residents • Selected 4 Navy coreman • knowledge first tract training WW2 • First class 1965 • 2 year Program, treat all ages www.aapa.org

20. Licensing of PAs • Licensed by the State • A PA shall be held accountable by state Medical Board • Certification exam • National Association of Physician Assistants

21. Numbers of PAs per Population www.NCCPA2019

22. ACPs Roles and Scope of Practice • promotion and maintenance of health; • prevention of illness and disability; • diagnosing, treating and managing acute and chronic illnesses; • consulting and referring to other providers • prescribing, administering tests, procedures and drugs; • ACP Providers Independent clinics SHVI www.aapa.org www.ncbon.org

23. SHVI Service Lines 2015 SHVI 5 Service Lines, TBC 1. Electrophysiology 2. Heart Failure 3. Interventional Cardiology 4. General Cardiology 5. Transplant Services

24. Added Value of ACPs • Case example complex patient Patient satisfaction Continuity of care Efficiency Quality of care • health care costs high rate physician burn out EMR This Photo by Unknown Author is licensed under CC BY-NC

25. High Quality Care HCT Case • Consult SHVI ER post procedure hemoptysis 41 yr old w/ hx congenital heart disease, S/P Tetralogy of Fallot w/ prior repairs, too high risk for pulmonary valve surgery & AAA repair followed by Dr. Alegria • S/P interventional cardiac catherization dilatation existing right pulmonary artery stent & implantation transcatheter pulmonary Melody valve

26. Complex case cont’d • TTE post procedure valve well positioned mild gradient, no effusions • 48 hours later temp 100.5, hemoptysis • CTA r/o dissection & PE, blood cultures • ID, pulmonary consult, pediatric TTE • Coordination of care 1.5 hours by ACP, 15 minutes seen MD • Discharged w/in 24 hours

27. Center for Advanced Practice (CAP) • Atrium Health is one of largest CAPs in U.S. optimizing the crucial role of ACPs in response to the changing healthcare delivery platform. • Employs over 1000 ACPs • A graduate adult gerontology acute care nurse practitioner (AGACNP) program in partnership with UNC-Charlotte • A 1 year paid, post-graduate ACP fellowship • 16 specialties, 45 Fellows per year

28. Concluding notes • Mayo clinic founded 1919 Dr. William Mayo, Dr. Charles Mayo & Dr. William W. Mayo • Motto “Only interest to consider is the best interest of the patient” • Health care teams are in the best interest of the patient

29. References American Academy of Physician Assistants (AAPA). Referenced from http://www.aapa.org Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record%5Fid=12956. Keeling, A.W. (2015). Historical Perspectives of an expanded role for nursing. Online Journal of Issues in Nursing, (20), 2. Kapu, A.N., Kleinpell, R. & Pilon, B. (2014). Quality and financial impact of adding nurse practitioners to inpatient care teams. Journal of Nursing Administation, 44(2), 87-96. Kovacs, RJ, & Drozda,J.P. (2015). The changing face of team care, and a challenge for the future. Journal of American College of Cardiology, 65(2), 2137-2139. Miller, A., Handberg, E.& Rogers, A. (2108). It takes a team to deliver optimal cardiac care. Journal of American College of Cardiology, 72 (8), 948-951. .