Site Management

AFCP pharmacist and patientThe goal of the AFQCP is to optimize care for AFIB patients.  It is key that all of the components are maintained during the process. It will be tempting during ‘real life’ running of the clinic to model it after existing clinic structures.  However, the goal is to actually change the system of care – not just to try to ‘add’ AFIB to an existing clinic.  The average time for us to assess, educate and engage our patients in their own care plan is about 90 minutes for a new patient – quite different from most clinics in the current system of care.  The important components of our program are:

Comprehensive management

As AFIB often has a number of associated conditions (CHF, HTN etc) we take responsibility to include strategies to optimize care for these conditions, in addition to the patient’s AFIB, in our Care Plan for the primary care team

Timely access

  • From ED to clinic : Our goal was to see patients within 5 business days of referral.  In reality, given the episodic nature of acute AFIB, there were occasions when we were outside of this window.  In addition, many patients rescheduled their own initial visit.  In these cases, we would screen for any newly initiated anticoagulation and ensure that the patient had access to more immediate care (for INR testing in new warfarin starts for example).
  • To cardiac diagnostics and specialist consultation: (See our “partnerships” under Construction Crew)
  • To an AFIB clinician when needed: To support patients, particularly with acute symptoms or urgent questions, they were given access to a 1-855 number to be connected with a clinician.  We had an average of 2-3 calls per week, some that directly prevented an ED visit according to the patients.

Patient Education and Engagement

Our goal was to ensure that by the end of each visit, the patient and family had a good understanding of their AFIB issues, how to manage them, what we were doing to help them and what the next steps in their care looked like.  This requires time spent engaging the patient in their care, creating mutually acceptable goals and ensuring they have an understanding of the time it may take to reach those goals

sitemanagement_circleofcareCare coordination and responsibility

The AFQCP needs to play a care coordination role as well – to ensure clear transfer of information to the patients Primary care team as well as to liase with other members of the patient’s circle of care.  The AFQCP team’s responsibilities are clearly communicated via the Care Plan

Early transition to Primary Care

This new model is intended to TRANSITION patients safely from acute care to their Primary Care team with support.  As such the goal is to ensure that once the initial assessment and diagnostic testing is completed and the patient is stable with a clear plan of care, that the patient gets transferred back with the 1-855 link to enable either the patient or the primary care team can reconnect the patients back to the AFQCP seamlessly.

Clear communication

This is accomplished via a standardized Care Plan structure and a commitment to provide that plan to the patient’s Primary care team within 48 hours of each visit, including any pertinent test results. View Provider Care Plan >>