The creation of an AFQCP begins with building your AFQCP care team and establishing the partnerships needed to really optimize the provision of care.
ED: A partnership with the referring Emergency Physicians is crucial to ensure safe referrals and communication of pertinent clinical information. In addition, their provision of patient instructions, and education packages to help initiate the education process and ensure the patients understand the next steps in their care was important to establish the initial connection between the patient and the AFQCP
Arrhythmia Specialists: This partnership was important to identify those patients at greatest need of specialist referral, and to create a clear pathway for that referral, including coordination of care and clear communication among the AFQCP, specialist and primary care provider. To demonstrate scalability, we incorporated Ontario Telemedicine services into our AFQCP to have the specialist connect to our clinic via Telemedicine for the initial referral and coordinated the timing with the patient’s next follow up visit if one was needed.
General Practitioner: As there were multiple different GPs whose patients were cared for in the AFQCP, our commitment to the GP was to ensure clear, consistent and timely communication after each patient visit. WE utilized the CARE PLAN structure to ensure consistent and guideline-based recommendations, and clear differentiation of the next steps in care, and who would take responsibility for the next steps. We then committed to providing that CARE PLAN within 48 hours of the patient’s visit.
Cardiologist: Some patients will require general cardiology follow up for cardiovascular conditions outside of their atrial fibrillation, such as newly diagnosed LV dysfunction, coronary disease etc. We incorporated general cardiologists into the clinic for coverage for our Internist and through our partnership for Cardiac Diagnostics. Our patients without an established Cardiologist were able to be quickly referred to this group as needed
Cardiac Diagnostics: As per the current guidelines for initial assessment of atrial fibrillation, patients require an evaluation of left ventricular function, most often via Echocardiography. In addition, certain patients may also require Holter monitoring, and other cardiac imaging for coronary disease. We established a partnership to facilitate access to these tests for our patients and timely access to their results for decision-making. Many patients were able to have their echocardiogram the same day as their initial visit.