Mastering the Cardiovascular Care Continuum

Strategies for Bridging Divides Among Providers and Across Time

Topics: Cardiovascular, Service Lines, Quality, Performance Improvement, Readmissions

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By reading this study, members will learn to:

  • Create an infrastructure capable of facilitating multidisciplinary collaboration
  • Optimize the use of multiple specialists and providers in cardiovascular patient care delivery
  • Transition patients successfully from an inpatient stay to the next care setting
  • Perfect disease management to provide postdischarge care
  • Increase patient retention by securing loyalty to the organization

Executive Summary

In the past, cardiovascular programs could focus solely on the acute care episode and realize significant success. However, these siloed operations have produced disturbing repercussions: fragmented treatment, suboptimal quality, and rising costs. Recognizing these shortcomings, market incentives have shifted to emphasize care coordination. Today’s progressive CV leaders recognize that care delivery no longer hinges on individual department performance but on bridging gaps among providers, between sites, and across time.

Establish the infrastructure for multidisciplinary care delivery

Currently, the total lifetime cost of treating a heart failure patient after diagnosis is over $100,000, much of which stems from the highly comorbid nature of this patient population. The complexity of treatment is clear— physicians must treat heart failure while simultaneously managing conditions such as hypertension, diabetes, and dysrhythmias. In many cases, multiple providers are participating in care of these patients.

To begin reducing these costs, programs must first establish an infrastructure conducive to collaboration through initiatives such as multispecialty strategy boards and committees. Cardiovascular service lines must then deliver multidisciplinary patient care by encouraging physician communication, promoting team-based care, and delineating the roles of generalists and specialists.

Perfect the patient transition and enhance longitudinal care

Because CV service lines’ purview extends beyond the acute care episode, streamlining the transfer of patients across care sites can be accomplished through the use of risk stratification, transitional coaches, and improved relationships with postacute providers.

Beyond transitional care, CV programs must aim to increase patient compliance over time and ensure longitudinal success by developing and enhancing disease management offerings.

An Increasingly Critical Mandate