To manage growing volumes, structural heart programs often jump to staffing as the primary challenge and solution. But given financial and resource constraints, programs must take a holistic view of efficiency to manage capacity and support long-term growth. Here are lessons from the market.

Strive to be a program that doesn’t require additional staff

At a baseline, efficiency starts with streamlining the TAVR procedure and care pathway itself. Below is a list of operational efficiencies to consider

• Optimize use of procedural areas—e.g., perform procedures in cath labs instead of ORs to decrease staff and overhead costs or refigure space and staffing for procedures, like TEER, that don’t require a surgeon.
• Streamline TAVR or other structural heart procedure days by stacking cases and cross-training staff—e.g., conduct procedures in one day by flipping between the OR and cath lab and leveraging cross-trained teams of OR, EP, and cath lab staff who can alternate conducting procedures as necessary.
• Prioritize certain procedural areas for structural heart—e.g., one program assessed what procedures should be done at what sites and now prioritizes TAVR, ablations, etc. for the cath lab and moved procedures like peripheral vascular elsewhere.
• Build in additional evaluation steps—e.g., protocols to proactively identify complications with the goal of streamlining recovery and ensuring efficiency gains are not lost.
• Adjust post-procedure recovery workflows—e.g., move patients away from surgical workflows and identify patients who can bypass the ICU, moving straight to telemetry unit or progressive care unit.
• Divide patient support between care settings—e.g., an advanced practice provider (APP) manages the patient in the outpatient setting and the nurse manages the patient in the inpatient setting, or valve clinic coordinator (VCC) handles pre-op and nurse navigator manages post-op.
• Expand outpatient operations—e.g., where possible, shift staff from inpatient hospital to conduct consults or other services in the outpatient setting to free up inpatient space, expand ambulatory footprint, and increase access.

The next step after addressing procedural and operational efficiency is becoming a lean and agile operation, especially for stand-alone and community hospitals. Programs should act on the imperatives detailed below.

Cross-train staff across structural heart procedures

Both structural heart coordinators and clinical teams should be able to manage different types of structural heart cases as needed. Programs early in the process of growing their structural heart program might have their staff specialize by procedure. But cross-training staff is critical to managing capacity as programs grow and evolve, especially given current challenges with staff turnover. For example, many programs have trained their cath lab team to do open cases and trained their OR team to handle catheters, wires, etc. Cross-trained staff can switch between procedures and rooms depending on need. For example, they can alternate between the OR and cath lab to complete more procedures in one day and minimize the need for physicians to come for an additional procedure day. An unforeseen benefit is that offering cross-training opportunities to staff has become an engagement driver and has helped to attract and retain staff.

Enable staff to work at top-of-license

Before making the next staffing investment, programs should assess whether existing staff capabilities properly align with tasks and workflows. By first investing in care team redesign to achieve top-of license care, programs or service lines might uncover FTEs that have additional capacity. For example, some programs have identified nonclinical staff who can support their program. Other programs have identified the need to off-load data registry at the program or organization level or outsource it to a vendor. Care team redesign not only improves efficiency and patient throughput but also increases patient satisfaction and access, improves revenue, and betters communication across the care team.

When approaching care team redesign, consider the specific needs of your program and how to appropriately allocate staff to ensure each team member is working top-of-license. First, work to upskill clinical practice across the team, making nursing staff responsible for practice operations and APPs responsible for appropriate aspects of CV patient care. Second, ensure nonclinical staff have full responsibility for non-clinical tasks. While each role has its own spectrum of responsibilities, remember that the structural heart care team functions holistically and will rely on inter-role collaboration to provide comprehensive care.

Develop scalable workflows to accommodate growth

Organizations are reconfiguring their workflows to reduce the burden on coordinators while also improving patient experience. For example, once patients are referred, they are triaged into standard clinical pathways based on their diagnosis. The pathways specify designated clinic days and imaging slots so patients can receive diagnostic services in a one-stop shop. Coordinators, providers, and the organization benefit from knowing what to expect when, and the institution as a whole benefits from the subsequent inter-department communication and efficiencies that result.

Decentralize ancillary equipment based on disease state

As structural heart volumes grow, ancillary services that feed multiple programs can act as a bottleneck, constraining capacity. To alleviate this problem, some programs invest in their own ancillary services. For example, programs can run dedicated imaging services that give priority to structural heart patients and then serve other patients as time allows. If such investments are not feasible, programs work with ancillary departments to create dedicated slots and days for structural heart.

Justify investment across the structural heart enterprise

To successfully secure funding for structural heart program investments, leaders and physicians work hand-in-hand to justify the program to both hospital/system administrators and philanthropy leaders. Here’s how:

• Illustrate growth outlook: Leaders continuously educate the enterprise about the value and necessity of structural heart (SH) and emphasize the distinctions of what makes SH unique compared to the rest of the cardiovascular service line.
• Demonstrate current performance: Leaders tell the story of where their program is, where they need to go, and how to get there. Data includes growth projections, referral volumes, halo effect volumes, quality outcomes, current and projected staff workloads, staff time study data, patient wait times, and patient stories.
• Articulate the need: Leaders proactively make the business case for the next investment a year or two in advance of program need and emphasize the projected benefits to patients, the program, and the institution at large. Most importantly, they paint the picture of what will be lost without investment.

To date, most structural heart programs have benefited from organic volume growth. However, with the explosive increase of structural heart programs in the market, leaders face increased competition to capture new and latent demand. If programs aren’t actively strategizing how to reach untapped patients, they risk falling behind. Here are lessons from the market.

Go to patients, don’t wait for them

Direct-to-consumer marketing is becoming baseline for structural heart programs. Leading organizations are going to patients proactively—not waiting for patients to come to them. Social media has become a critical avenue for program marketing, surpassing commercials, mailers, and other traditional advertising channels. Organizations are leveraging social media as a tool to educate and attract patients—and patients are responding. In some cases, these efforts have brought patients directly to the program, bypassing the referring physician and helping to create the right payer mix to financially support the program. Direct-to-consumer marketing is especially critical for community hospitals and those serving rural markets.

Expand your net to capture potential at-risk patients

Referring physicians already have the difficult job of seeing patients across a wide spectrum of diseases. To reduce the burden of testing and treatment recommendation on the part of referring physicians, structural heart programs should have those providers refer patients with any potential form of valve disease rather than referring for specific procedures (e.g., TAVR or surgical intervention). By adopting this valve disease model and casting a wide net for patients, programs start to address the challenges of underdiagnoses and undertreatment on the side of the referring provider.

By assessing a greater number of patients at the point of referral, structural heart programs are hoping to see volume growth across service offerings. In particular, one program is hoping that by having their structural heart APPs triage patients at the onset of referral, they can increase their conversion rate of testing to procedure from 60% to 80%. Smaller hospitals without capacity may not be able to implement this “come all” approach, but can still ensure that referring is as easy as possible for referring providers.

Rethink outreach and access with a health equity lens

Studies show disparities in access to structural heart procedures. For example, research has found that racial minorities are underrepresented among patients undergoing TAVR in the United States. Another study found that with every $10,000 increase in income, the odds of receiving TAVR increased by 10%.

Structural heart leaders are increasingly recognizing that disparities exist between the patients who seek care and the communities they are serving. Consequently, organizations are investing in strategies to reach those patients and close the access gap.

With TAVR becoming a mainstream procedure for cardiovascular service lines,structural heart leaders are making sizable investments to differentiate theirprograms from their peers in terms of access and patient experience. Here arelessons from the market.

Actively market your structural heart vision

TAVR growth has benefited from industry-wide education and advertising. But given the significant underdiagnoses and treatment of aortic stenosis, there is still a large opportunity to capture latent demand by educating patients and referring providers. To lead in the structural heart market, programs need to leverage TAVR marketing efforts to make the case for their structural heart program as a whole—and capture demand across all structural heart procedures. That’s because future competition won’t be for just TAVR—there will be competition across structural heart offerings.

Key components of structural heart program marketing

• Educate patients and referring providers about the multidisciplinary approach of your structural heart program.
• Highlight the quality outcomes of your program.
• Illustrate the experience patients will have by receiving care through your program.
• Share patient stories from the community that future patients can relate to.
• Include provider and staff backgrounds to showcase the diversity and experience of your program’s staff.
• Provide timely feedback to referring providers on patient decisions and procedure status to encourage future referrals.
  
  

Leverage quality as the vehicle for differentiation

A focus on demonstrated quality outcomes can set programs apart for patients, providers, and payers. For example, some programs seek accreditation to signal that they are a center of excellence. As the influence of consumerism grows in structural heart, the importance of quality ratings reports will also increase. In particular, younger patients and patients’ families are more likely to “shop” for care and will expect more from programs in terms of data transparency, accreditations, and program and institution rankings. Consequently, many programs are investing in additional staff time and technology solutions to specifically support data registry, or outsourcing the tasks to a vendor.

Moreover, programs who can demonstrate a quality-driven patient experience report using their quality data to renegotiate commercial payer contracts to improve financial margins and prepare for future payer steerage to high-outcome programs. To see an example in action, see the St. Charles case on pages 20.

Distinguish program to attract new, high-quality talent

Staffing is an evergreen challenge for health care, and structural heart is no exception to the effects of turnover and retirement. Organizations are actively selling their structural heart programs to new graduates and are highlighting early career advancement opportunities, access to premier technology, program accolades, and efficiencies that provide improved work-life balance compared to other programs. For example, one structural heart program in a rural area recruited a recently graduated interventional cardiologist (who had done an extra year of fellowship for structural heart) by offering mentorship opportunities with the head of their recently established program. Another program has retained newer staff by scoping the coordinator role and emphasizing work-life balance best practices such as not answering email after hours.

Differentiate through referring physician experience—not just patient experience

Leading structural heart programs are not just looking at building relationships with referring physicians but creating a referring physician experience to differentiate their program within the community.

Through physician liaisons or structural heart physician roadshow tours, programs paint the vision of their structural heart program and educate referring providers on the experience their program offers to both the patient and provider. Contact with referring physicians should be conducted continuously, emphasize quality outcomes and the most up-to-date industry research, and reiterate the handoff process post-procedure.