Part of our why, regardless of our actual day-to-day duties, has to be about the people that we serve, patients and caregivers alike. Now, we're going to think through their experience, from the patient journey and our role in it, to telemedicine and how that affects the way that we work. This next section is super important. Let's continue to learn together as we take a look at the patient and caregiver experience. In this next segment, we'll be talking about the Grandview model from the patient and caregiver perspective. And joining Jose and myself is Merit White, who's the inpatient nurse practitioner here for the EP program. Jose, how has the approach that you guys have taken to patient care here been? And how have you angled this from the patient and caregiver perspective? Paul, we all understand and agree that health care is complex. So if it's complex for physicians and nurses practitioners, imagine from the patient perspective, right? It can be actually chaotic is the right word. So patients have to achieve comfort and calm with the care and the experience they're having, that we have to educate them and set the expectations and really hold their hand through the whole journey. So I think similar to other topics we've discussed along the series in terms of mapping out everything, you need to do the same from the patient perspective so that you plan things in a way that patients and family members know what to expect and will engage and participate in their care that way. So the patient journey is something that you have should map out. And then with that, create the processes that will increase engagement and improve the outcomes of the patient. So I think very similar to other conversations we've had. Interesting. So then I would imagine that having the clear time expectations of exactly how things would go would be somewhat comforting for patients to know exactly what to expect. Absolutely agree. And it starts in the clinic, right? It starts, or today via telemedicine appointment, when you are discussing with the patient about their treatment options and educating the patients and the entire shared decision making process, it really starts there. But once that decision to have a procedure has been made, then it's on us to really set that expectations for the whole journey. So what we have done, starting in the clinic, is we have created brochures that address the entire journey that we give to the patients and family members, along with educational brochures about atrial fibrillation. So there's two separate pieces of materials that they'll get. And in terms of the day of procedure brochure we've created, it's as simple as, this is the map. These are hotels around our institution. And on the day of procedure, where you're going to go, you may have a transesophageal echo. You're going to have to have an IV. You're going to meet the anesthesiologist. For the family members, this is where the cafeteria is. And so that everything, when the patient comes, they should know how their day is going to go. And once the procedure is complete, then I think there's an even more important aspect that we should discuss, which is the post-procedure education with the patient and family members and post-procedure care. Now, if I understand correctly, the majority of your patients are same-day discharges, especially for early in the day cases, correct? That is something that we had been doing, same-day discharge for about, talking about specifically AF ablations, for probably 20%, 30% of our patients up until COVID happened. And at that point, we had to adapt and find ways to increase same-day discharge for the safety of our patients. And that required an even more care in terms of the logistics, meaning we had to coordinate that patients understand, you need to have a hotel around if you live an hour or more away, the patient education aspect. So that's when the coordination of the care and discharge process became more complex. But I think with the help of Merit and our inpatient providers, we have created a process that we feel good about, which is delivering that in small increments to the patient, family members, and then the process of post-procedure continuing education with phone calls and clinic engagement as needed based on the complexity of the case. Great. Merit, let me turn to you. Can you tell me a little bit about your experiences and how you see this and how patients experience things? Sure. So my involvement is strictly inpatient, and unless I'm covering, and that's very rare in clinic. So I do get the opportunity for a lot of education, which is one of the things that I love the most about my job, is actually getting to engage with patients, engage with family members. Post-procedure is where that really involves a lot of what I do. After the procedure, of course, when the patient is a little bit more awake, when family's present, we go through discharge instructions. Some days, I think I feel like a robot. I just want to put it on the loudspeaker and play it for everybody because I say it so much, but I don't think you can hear it enough. And so we go through with the patients. We are very specific about restrictions, what to do, what not to do, when you can drive, when you can shower, can you go upstairs. I mean, it's very detailed. Medications are gone over with a lot of care because, quite frankly, many patients don't know what they take. Oh, well, it's this little round pill, or oh, my wife makes my medicines in my pillbox for me. And so to do that and involve the families and engage them is very, very important. The following day, our nurse, we have an EP nurse that's strictly designated for the hospital. Either she or I will call patients, go back over it again. We find that a lot of times they don't remember anything that we've said, which is why I always make sure that there is a family member, another set of ears for the discharge process. And I think we've learned, although it can be a little tedious when you're doing 10, 15 AFib ablations a day with all three of you guys combined, the process takes a little while. But what we have found is it's so important for this next day follow-up call because the patients don't remember. And the family member that brought them may not be the family that lives there. And so I think that educating them, you just can't do enough of it. So Merritt, with doing this 10 or 15 times a day for multiple patients from multiple labs, do you have standardized scripts that you've written out to protocolize all this? I do. So when we first came here, I worked very closely with, her name is Jenny Breeland. She is, I don't know what her actual title is. She wears a lot of hats. But she and I worked very closely and developed a lot of these protocols and these discharge instructions. And so I was fortunate enough to be able to have a hand in a good bit of this process. And so it's pretty standardized. I mean, everybody kind of gets the same instruction with their specifics individualized. But anyone could come in and discharge one of these patients because all the standards are there. It's all the same. Everyone pretty much has the same discharge instructions, which we did this because on the weekends, if we do procedures, for example, on a Friday, if one of the general cardiology nurse practitioners is here on a weekend and it's not one of the EPs, then anyone can discharge one of our patients and know exactly what we expect and what we want. Well, I'll add to that in the interest of standardization, patient gets into the lab, we do have a checklist, really a checklist that we will, the nurse in the room will double check. What is the anticoagulation regimen? Did the patient take? What was the last dose? Does the patient have an ICD? Did you turn off ICD? So all of these things that you don't want to forget in a procedure. And before they leave the room, did you turn back on the ICD, defibrillator therapies? So we go through a checklist before they leave the room. If it's a patient that is going to be a same-day discharge, we have another checklist that we follow. Before discharge, there is a checklist that now that we started in the room and it's continued in prep and recovery. So did you complete bed rest, ambulation, any issues? And so that checklist is continued by either Merritt or Bethany the day after and when we make that patient phone call. So that patient phone call is not just scripted to elicit answers to specific complications we want to look for, but also we continue a checklist and document. At the one-week follow-up, all patients, all procedures have another phone call by our clinic nurses at that point. And templated checklists were created on the EMR so that they just follow the script. And then if there are any questions that the answer, you have concerns about, the physicians are flagged for a phone call or a patient visit to the AF clinic, which is led by nurse practitioners. And for both of you, how do you find that patients and their caregivers respond to these kinds of approaches? I think very well. I don't, I rarely have a patient or a family member unhappy with their post-procedure education and what to expect. Like I said, a lot of patients may not remember us talking to them. But at the same day, at the next day phone call, they, oh, well, thank you for going over this. This was very helpful. This was very informative. I think for the most part, people respond well. And they like our process. And they appreciate our care and what we're doing. I think Merit is not emphasizing enough how great of a job is done and the impact that this has to the patients. When I see patients in follow-up, it's rare that someone doesn't comment about that process. It's really rare. Most patients and family members will just comment multiple times about the entire process, how it felt smooth, it felt they knew what to expect. And that phone call the next day and then a week later, it means a lot to patients and family members, because it's not unusual, for example, in as much education as we give to our patients to, at seven days, you find out that someone decided to stop their blood thinner. And so things that could have really bad consequences because of lack of education. And so if something happens, that series of phone calls will pick up problems. So patients feel, I mean, they feel like we're holding their hands through this journey. Post-procedure care for AF ablation is complex. And also, I think from a services standpoint, what we have found is the more education we do, the fewer phone calls we get. So we are really preemptively addressing problems or potential problems and educating patients to having some chest tightness when you take a deep breath for a day or so, it may happen. So because they know they're comforted, they're not going to call our office. So it ends up helping the patient, the family members, but it helps our service improve the flow, too. Interesting. So a couple other questions. How have you adjusted your protocols for managing all of these things with dealing with the global pandemic of COVID-19 that has affected all of us? You hinted at this a little bit in saying you'd increase the number of same-day discharges. But are there any other things that you've implemented in the process of doing all this? So I think if there's one important message in terms of the same-day discharge, and the change is what Merit talked about, you discharge a patient the day of the procedure. After having received sedation that day, they may look and talk to you as if things are normal, but odds are they're not going to remember a word. So doing patient education the day of a procedure and discharging the patient that day, we assume they're not going to remember anything. So contacting the patient the next day has become very important. The other part that we have found is that for same-day discharge to be successful, it starts in the clinic. Because we have to set the expectations with the patients. You plan on going home. And if they say, well, I live four or five hours away, plan on having a hotel around the hospital and give you a call. So we have found that patients have also become a lot more interested in the concept of going home same day. They don't want to spend unnecessary time in the hospital anymore. So that facilitated a lot. But the coordination to make it successful, I think the pandemic made us have to adapt significantly, wouldn't you say? I think so. And I think people have been very receptive about same-day discharge. I was a little skeptical at first because it's just so different from what we've done. But patients really, once you explain to them, because they are a little nervous as well. Well, I just had this procedure. What if my groin bleeds? What if I have chest pain? What if this, that, and the other? But I think with the education, with talking to them, with them understanding the expectations, they've been very receptive. And people now are asking, well, can I go home today? Versus, can I spend the night in the hospital? I very rarely have someone say, oh, I'd really like to stay. So I think that it's worked well. The process has worked very well. The other aspect that has changed, and I believe for the better, is the ability to use telemedicine. So we have been using telemedicine for many years. But before, because of reimbursement options for telemedicine were very limited, we were using for a small number of patients that were either cash pay or some insurances that would allow. But now, we have completely incorporated telemedicine to the transition of care model. And I think that's probably one of the most successful and important ways to use telemedicine. Any patient that is being discharged, and AF, AFib with a low EF, and high blood pressure, we will have a seven-day telemedicine visit with our nurse practitioner. So incorporating this into our protocols, particularly if you are treating patients that live within hours away, and you don't want those patients to go to an emergency room because of something that you could address. So the incorporation of telemedicine and the same-day discharge, I would say, are the two most important changes to our service over the past year. Well, if there are any silver linings to this awful pandemic, those are going to be some positive changes that I think everyone would agree would be in support of patients and that people would take care of them. Telemedicine has been wonderful. I really think that it has increased patient compliance, overall outcomes, and satisfaction. I think I echo what Dr. Osorio says. We have a very wide referral base. We see patients from Tennessee, from Texas, all over the country. Having a way to see someone, to have a face-to-face or a phone if they don't have the ability to have a camera, a smartphone, whatever the case may be, having direct access to their providers, I think, makes a huge difference in overall patient outcome. We don't want someone to go to an ER where the understanding of what we've done or the level of complexity may not be something that they're used to. We want to try to prevent re-hospitalizations. We want to try to increase patient comfort and satisfaction. So telemedicine, I totally agree. I think if any good thing has come from this, I think utilizing that more has been fantastic. I really do. We talk a lot about the fact that much of what we do is protocol, standardization. So as we increase the number of patients that we're evaluating from other states, one consequence we had years ago was the number of patients that weren't returning for follow-up was increasing. Patients didn't want to drive six hours to come see follow-up. And now, I mean, I think this is very patient-centered. We continue to do the follow-up. If there's an echocardiogram, if there's a monitor, there's something that needs to be done, they can go to their local cardiologist and we continue to work with them. So I think it has allowed us to be even more patient-centered. I would imagine in that very wide geographic referral base, you're also dealing with a very wide range of degrees of education and education level and health literacy among the patients. How do you manage dealing with such a complex patient population? The education has to be standardized, but it requires someone like Merit that will change it to the level of the patient, right? It requires physicians that are willing also to bring it to their level, you know? So we have typically designed this educational materials and brochures to someone at a certain health literacy level, but we need to be open to give more or less. So we also have a website that has a lot of education, for example, and that it will go from simple with videos, with some text about AF ablation, all the way to blog entries with more complex discussions for patients that want. So I think you cater to your audience. It has to be done that way, and so that's why you'll develop the basic and brochures, educational materials, but you need to always be willing to get to as much or as little as the patient wants. Just you have to make sure they're well-educated. I think, too, looking at the patient as a whole, it's very easy, especially with us being so specialized with what we do, it's very easy to focus on a patient's AFib and let that be the only thing that we're talking about, but it's very easy to forget, well, this patient also has CHF, and so educating patients about the whole complexity of their health issues, I think, is a very big deal. I have patients I see all the time, well, no one ever told me I needed to be compliant with a low-sodium diet. Nobody ever talked to me about this. No one ever talked to me about nutrition, and we see them in conjunction so much, heart failure and AFib and at discharge, looking at the meds, making sure that they are on a good CHF regimen, making sure that we do a transition of care with our CHF nurse practitioner and that staff. We have a nutritionist. They spend hours with patients going through this sort of thing, and so I think that looking at things as a whole, educating people, like you said, based on their understanding and just adjusting the way that you need to adjust to make sure that people stay out of the hospital. I mean, we know our literature continues to evolve on this, that for you to be successful with AFiblation, you need to treat their blood pressure. You need to focus on weight loss. You need to make sure we've evaluated patients for sleep apnea, so that, I think, the best way to be successful with that is creating protocols as well because it's easy to forget on a busy clinic day and skip one of these steps, right? So if you build things into your flow, and I think this is perhaps where it's the best example of how healthcare today, it's a team sport. It has to be a team, and our patients have that. They have the AFib clinic nurse practitioners. They have the ability to see a nurse practitioner as a walk-in any time. We have patients that, upon discharge, we will do blood pressure log and some degree of remote patient monitoring, and we will work with the patient to get blood pressure control. Referral to sleep studies is almost 100% of the patients now. So I think this shows, this highlights the complexity of the care, and as an individual, a physician can fail if you create a system that hinges upon a single person. So protocols and the team approach is the way to be successful, and patients feel it. They feel it, and we have a lot of patients that, through the process of us taking care of their atrial fibrillation, end up wanting to rely on us for other things, other aspects of their care. All the way to, I mean, very simple is their hypertension care. And so I think that's very important, and it's patient-centered. That's the key message here. Well, it really seems clear that the standardization you've taken in other areas has very much applied to streamlining the experience that patients and family members have gone through in the process of undergoing afib ablation here. And thank you both for your comments. Thank you.

patient and caregiver experience

clear communication

education

telemedicine

patient outcomes

team-based approach