Cardiovascular Team-Based Care | Ten Points to Remember

Brush JE, Handberg EM, Biga C, et al.
2015 ACC Health Policy Statement on Cardiovascular Team-Based Care and the Role of Advanced Practice Providers. J Am Coll Cardiol 2015;65:2118-2136.

The following are 10 points to remember about the 2015 American College of Cardiology (ACC) Health Policy Statement on cardiovascular team-based care and the role of advanced practice providers (APPs):

  1. The purpose of this health policy statement is to inform ACC members and the public about the capabilities of APPs, discuss barriers to cardiovascular team-based care, offer examples of successful cardiovascular team-based care, and provide recommendations for improving the provision of cardiovascular team-based care.
  2. APPs include cardiologists; advanced practice registered nurses (APRNs), including nurse practitioners (NPs) and clinical nurse specialists (CNSs); physician assistants (PAs); pharmacists (PharmDs); and registered nurses (RNs).
  3. Members of the cardiovascular care team can come from a variety of professional disciplines with distinct education and training pathways, resulting in a rich diversity of talent and capabilities. The diversity of backgrounds for APPs should be viewed as an asset for the team.
  4. All cardiovascular APPs are taught problem-solving algorithms, treatment protocols, procedures, and standards for general cardiovascular care. Some APPs are taught to practice in a focused area of cardiovascular care, such as heart failure. The tasks of physician assistants tend to be modeled on the technical and clinical tasks of the physicians, expanding the overall capabilities of physician-led teams; PharmDs may be focused on tasks such as medication reconciliation during care transitions, improving medication adherence, providing prevention care, and managing complex drug therapy.
  5. A useful motto for cardiovascular team-based care is “shared goals and clear roles.” Each team member should have a clear understanding of his or her functions, responsibilities, and what is expected of him or her.
  6. Historically, the leader of a cardiovascular team has been a cardiologist. It is the position of this writing group that leadership should be flexible, reflecting the specific needs of the patient at a particular time and setting. For example, a nurse or a pharmacist may lead a team that organizes a chronic anticoagulation clinic. The leader should be the team member with the greatest knowledge and experience and the best qualifications for the leadership task at hand. For clinical leadership, the most important factor for determining the leader is the amount of knowledge, training, and experience a person brings to the task; for most clinical matters of cardiovascular team-based care, the overall leader will be a cardiologist.
  7. There are differences between states in regulations defining prescriptive authority among providers. Inconsistencies between states affecting what PAs, APRNs, and PharmDs are licensed to prescribe can become a barrier to a broad-based implementation of cardiovascular care teams, and can create impediments to the development of national standards for cardiovascular team-based care.
  8. Payment rules by Medicare and commercial payers also can serve as a barrier to cardiovascular team-based care, with different standards for billing in inpatient and outpatient settings. In the office, the APP can provide services that provide both better access for patients and practice income. In the hospital, the APP does not submit a bill for a shared visit, but the cost of the APP’s activity can be justified by gain in physician efficiency. Going forward, cardiovascular team-based care will need to successfully navigate a transition to new payment models.
  9. Examples of effective cardiovascular team-based care include chronic heart failure management, lipid clinics, hypertension clinics, anticoagulation clinics, exercise stress laboratories, arrhythmia management for pacemakers and implantable defibrillators, and outreach to rural clinics and remote locations.
  10. Broad dissemination of cardiovascular team-based care paradigms can be realized by further educating the cardiology community about their components, characteristics, and potential to improve patient outcomes.

Keywords: Algorithms, Arrhythmias, Cardiac, Clinical Protocols, Defibrillators, Implantable, Health Policy, Heart Failure, Hypertension, Inpatients, Leadership, Lipids, Medicare, Medication Adherence, Medication Reconciliation, Medication Therapy Management, Nurse Clinicians, Nurse Practitioners, Nurses, Outpatients, Patient Outcome Assessment, Patient Care, Pharmacists, Physician Assistants

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