Ellen Berger. Hi, I'm Caitlin Lobdell. I'm a cardiologist here in upstate New York at Capital Cardiology Associates. I'm the director of nursing here at Capital Cardiology. And today we're just gonna talk to you about our cardiac urgent care, also could be called a cardiac walk-in clinic that we started back in 2014. Just to give a little bit of background on the program. In 2014, we were really looking for ways to decrease the cost of care in the community. And all of us, all of the cardiologists were seeing patients in the emergency room that did not need to be in the emergency room. That we knew if we saw them in the office and were able to control imaging as well as lab work, that we could throughput them much faster the patients would be very unlikely that the patients would wind up on observation status and seen by hospitalists. And so we said, let's give it a try. So in that year, we took the area that used to be our medical records section, like our paper medical records that we no longer needed. And we created six bays and we hired, or we moved Caitlin over from doing stress testing to be the head of our urgent care. And we bought some telemetry off of eBay and Lee said, let's just open this up to the population. So we're gonna go through our slides and see what's happened. Yes, thank you so much for introducing yourselves. We are so grateful for your time. I know we have lots of people interested today. And as we get started, as many of you saw, we had a lot of engagement in response to wanting to learn about your program. We definitely see the need within cardiology to meet those patients that are kind of in the middle. They're not quite sick enough for emergent care, but they're not stable enough for that traditional outpatient next available appointment. So we actually recognized this need last year and we've been spending some time with Dr. Sullenberger and team and some other programs with a diversity of geographies to learn about these models. So we're really excited to have you all here because there's no one size fits all. So personally wanna say thank you so much for joining on short notice. And as we get started, I'm just gonna go over a few housekeeping rules. And really we do want this to be an interactive session and please ask your questions. So Dr. Sullenberger and Caitlin will go over a presentation and we will have time at the end of that presentation for you all to submit questions. And then we will have a Q&A. Please direct all questions through the Q&A side. We will be interacting through that channel. So we will read those questions and any questions we don't get to, we can circle back after the webinar. And through the chat option, you will be able to access the PowerPoint. So again, if you'll wait till the end, we will give you the opportunity to engage and ask those questions. Thank you, Dr. Sullenberger and Caitlin for joining us today. We're excited to hear about your model. Great, thank you. You can go to the next slide. So we're a fairly large cardiology practice in upstate New York. We have 35 cardiologists include all of the subspecialties of cardiology that you would expect, including a lot of non-invasive and imaging cardiologists, electrophysiology, structural, interventional advanced heart failure. When the slide was done, we had 21 advanced practitioners. It's up to 24 advanced practitioners now and three major office locations in different cities. And we've just opened a couple of other satellites. So I would say now we have three major and two sort of minor office locations. Next slide. So the problem, as I stated in the intro is that there were too many patients in the emergency room with symptoms that could be cardiac, but were unlikely to be truly cardiac emergencies. And when you're a cardiologist in the emergency room, you really have very little control. I mean, you have the control of whether or not whether or not the patient should be taken to the cath lab. But outside of that, a lot of it is under the control of the hospital system, either the ER doctors or the hospitalists. And in my view, it led to a lot of unnecessary observation admissions and a lot of ER testing that didn't need to be done. Particularly, everybody seems to get a CT scan to rule out PE in every patient. And we thought, well, why don't we create an urgent care in our office? So instead of patients being sent to an emergency room to be evaluated for symptoms that are possible, but not really likely to be cardiac, but we're able to make those determinations in a much more efficient and cost-effective manner because we control the imaging and we don't have to worry about other doctors like ER doctors or hospitalists touching the patient or putting orders on the patient. So next slide, please. Like I said, we created initially six bays. We didn't know how this was gonna go. Those bays that I talk about are sort of a pod system that you see right here on this picture. Now, this allowed us the ability to, it's really furniture. It's not necessarily a reconfiguration that required city approval or building approval. It also could be depreciated within a year rather than having to depreciate over time. So it made it a more cost-effective way to experiment with this model. You'll notice that the bays don't reach all the way to the ceiling. So there is sometimes some questions about, what about privacy issues? But really you're comparing it to privacy of an emergency room, which all of us have been to emergency room and there's not really that much privacy and really true healthcare data that identifies a patient is not being spoken out loud. So I'm not worried about the patient next door hearing like the patient's name and date of birth and those types of things. We purchased telemetry. Telemetry is very expensive. So we actually bought initially cause we didn't know how this was gonna go. We bought it off of eBay, off of a closing cardiac rehab site in New Jersey and they came and set it up for us. So the guy was nice enough to do that. We put hired an RN with cardiac experience here, but Caitlin actually worked for us at the time. She was a new nurse doing stress testing and we moved her over because she had been in one of the hospitals and a CCU. So she had CCU experience. We increased, we had an in-house lab already and we increased the lab analysis to allow stat troponin and BNP. And then it really came down to education and educating our own nurses who take the calls and educating our own patients as well as local primary care providers and even emergency rooms. And what the real change was is instead of our nurses telling patients, oh, you should go to the emergency room, you're short of breath, it's just come in. And that became a just come in and be seen. In local primary care offices, I would go around and give talks educating them that they could just send the patient over any patient with say palpitations or uncontrolled blood pressure or AFib with RVR or heart failure, but not so bad that they were hypoxic, but bad enough that they needed IV diuretics. Certainly people who had had an episode of chest pain, primary care deals a lot with, oh, I had chest pain over the weekend, but I didn't seek any attention at that time. And now it's a Monday or a Tuesday. And the primaries at the time were left with, I guess I'll send the patient to the emergency room because I don't want to miss something. And this allowed them just to send it to our office. For emergency rooms, it became talking to them about what we were offering and as an easy way for patients to be followed up who went to the emergency room with chest discomfort or something else that needed cardiology follow-up. Instead of saying, oh, call and schedule an appointment, they could just tell the patient, show up Monday morning at 8 a.m. or show up tomorrow morning at 8 a.m. at this site. Next slide. So patients that we really see a lot of, chest pain, shortness of breath, palpitations, hypertension, AFib with RVR. We see a lot of urgent pre-ops coming in from orthopedic or other surgical groups and then syncope. And what initially happens is the patient is triaged by one of the nurses. Every patient gets labs, a full set of labs and EKG and vital signs. And then the patient is seen by one of the advanced practitioners who performs the initial evaluation. And the patients are then evaluated by the cardiologist depending on the urgency. And I'll talk about a little bit of how the model has changed over time in that regard. So we have all sorts of diagnostic testing that we have altered our schedules and bonused our schedules to allow add-on testing. So that would include stress testing, echocardiography, CT scanning, everything from just calcium scores to coronary CT angiograms, to triple rule-outs and chest CTs. And then obviously outpatient telemetry and then ultrasound for DVT and vascular. Next slide. So initially we opened in March of 2014 and you have two different bar graphs here. One is distinct patients and one is total visits. And you can see how over time, the number of distinct patients and total visits just really took off. And it was really around 2017 where we hit the tipping point. This year, I don't have 2023 on there, but in 2023, the number was about 14,000 visits across all of our ECAs. This year, it's gonna top 16,000. And then the distinct patients last year topped over 10,000. Next slide. So when this slide was made, we had two sites, Albany, which has expanded to 14 bays. And the second site in Clifton Park, which is 12 bays. We also have a third site now in Niskayuna, which has 12 bays. And in Albany, in general, there's about on average 41 patients a day. These are unscheduled, mostly unscheduled walk-in patients, a third of which are new patients to the practice. In Clifton Park, it's more around 20 to 25, now it's about up to 25 patients a day and a third are new patients. So when I originally created this model, I can tell you and had to sort of sell it to my partners. The thought was we would send about 80% of the patients home or 85 and admit about 15%. And it's been much different. We send home about 96% of the patients and only 4% are sent to the hospital. Now those 4% that are sent to the hospital, some of those go direct to the cath lab because they're actually having a myocardial infarction, they have positive troponins and active chest pain. We occasionally get a STEMI, it's not that common as you might think, but it does happen occasionally. Some of it is heart failure and some of it is a need for catheterization, but yet maybe they're on Eliquis or something, we just wanna set them up for an urgent cath tomorrow, so we admit them. How do I put it? In the days when hospitals were well-staffed with nursing and beds were readily available, we would admit directly to our service at each hospital to try to save and bypass the ER. We still try to do that now during COVID and that post-COVID period, it got a little touchy and you could not necessarily get direct admissions, but that's coming back to be something we do more of now. And then occasionally we do have to send patients to the ER either if there are no beds available, even if the patient's a cardiac, or obviously some patients show up and their shortness of breath is pneumonia or anemia. And it's not a cardiac issue, but the patient needs to be evaluated in a rapid manner, we'll send those patients to an emergency room. Next slide. We have all sorts of cardiac testing available and on these presentations, people always ask me, what do you need to do it? You certainly need echo and you certainly need CT scanning. I don't think you can do it very easily. I'm not exactly sure how you would work it without those two modalities in a manner in which you're providing the best practices. So echo, I think the last time I looked, it was about 18 to 20% of patients were getting an echocardiogram. CT scanning, it's about 12% of all visits and that includes everything from calcium scoring to CTAs to P's to triple rule-outs. Now a smattering in there are things like regular stress testing. Occasionally we'll add on nuclear imaging, that's a little more unusual. Sometimes we'll do rest technetium injections because the patient's having active chest pain, but we're just trying to get images during the time of chest pain, so we'll add that on. We also have PET scanning, but PET scanning usually is not done because it is very unusual in our population that somebody has not ingested caffeine in the last 24 hours. Next slide. And then that was more about CT scanning. I'm just gonna, can you go to the next slide? I think the next slide's on questions. I just wanna take over, I'm gonna share my screen here and I'll show you how this works. So hopefully, Jenny, can you see that screen? Is that a Google spreadsheet on there? Yes, we can see it. Perfect, okay. So this is just an example of every day we create a sheet like this that we have on the board, both a electronic board in our ECA and in the nursing station. You can see this is today. It looks like there's still a few patients in the urgent care. We try to move everybody out by five o'clock. The patients are identified with their first name, their diagnoses. These patients are seeing both a physician and an advanced practitioner and the labs look like they're pending. And you can see that this patient's already got an MCOT. There doesn't look like to be testing ordered on any of these, but for earlier today, these are patients that were already seen and discharged from the ECA earlier today. And I'll point out, new patient, is anybody with an X in this column here? And so as we scan down, you can see how many of these are new patients to our practice. And this is just one day all of these patients came in. So it looks like it's gonna be a little over 40 patients today. And then this is the testing that was done today. It doesn't look like a lot of CT scans, but a lot of stress tests, echocardiograms, MCOTs. And then we keep track of what time the patient was discharged and where they went. And it looks like everybody went home today, except for this patient, ended up having to be taken to the emergency room. This is an example. This is the Clifton Park. This was on Monday and you can see, this is in a satellite location. Most of the patients seen this day were new patients, just walking in unscheduled. There was not a lot of testing on this day, but you know these new patients, most of them are gonna come back and see us. So this provided us, I can stop sharing. This provided us the opportunity to really change the dynamic locally. We, at one point we're sort of dependent on, oh, are the, cause we're a private practice, right? Are the hospitals gonna give us ER call, you know, as a source of new patients. And now the vast majority of our new patients walk into our office. We really don't need ER call to maintain any sort of source of new patient referrals. So that really led to leverage with the hospitals. It also, because we have two competing hospital systems and we control where any admissions from the ECA go, it also allows us a little bit of leverage in that scenario. So that's it. I'm gonna ask Caitlin if she has anything to add from... No, I think that was a really great overview. Initially, when this started, we started out with one cardiologist staffing this and that cardiologist had their own office. And then any of the patients that came in, they would see them also. And then as it took off, we said, okay, we need two cardiologists to do this because the volume's a little bit too much. So then there was two cardiologists and eight bays and each cardiologist had their own office schedule. Then it became, we needed an advanced practitioners to help because the volume was so much that the providers couldn't see their own patients and also cover the ECA. And then it's just taken off since then. Right now in the Albany office, it's really staffed with usually three to more like four advanced practitioners and then three cardiologists, all of whom have their own office schedule. What we've learned over time is that in the past, we made it where the advanced practitioner would see the patient and the cardiologist always saw the patient before they were discharged. We've learned over time that doesn't need to be done, that most or a lot of the patients can just be seen by an advanced practitioner as long as there are staffing, there's overview by cardiologists available. And as places grow, it's harder to hire a cardiologist than it is to hire a good advanced practitioner. So that makes it easier to staff these scenarios, but you do have to have somebody available. You also have to have somebody available to read all imaging, right? Because imaging is being ordered. It needs to be read and interpreted right away. So we always have somebody available who can read CT scans. And for those advanced practitioners, if they need an echo read, there's always an echo coverage situation there also. I think we have learned a lot. I was initially worried about, I don't know. Initially we were worried about things like, well, the hospital's not like this. The hospitals love it. They think it's the greatest thing ever. I've had multiple ER doctors tell me it changed the whole face of everything because it's so easy to get patients seen right away that they like it because it decreases their liability for sending somebody out of the ER to home. Primary care providers love it because they don't have to send a patient. People hate going to the emergency room. And even if they have a wait in our office, our competition is the emergency rooms, right? We know we're seeing everybody and getting them out by five o'clock. An emergency room, they can sit there as you can hear horror stories of 18 hours without being seen. So when that's the competition, that makes it easy to beat. And then patients love it because it allows them the ability to come in and be seen if they have a concern. Our physicians love it. It's a difficult situation to, you know, it's tough. It's a lot of, it's sometimes extra work on some days when there needs to be a lot of staffing. That being said, most of the time, you know, in about 70 to 75% of the cases, the advanced practitioners can take care and disposition the patients effectively. In terms of revenue generation, you know, patients love it because it's an office copay. It's not a hospital or ER copay or an urgent care copay. The patients also love it because they know they're gonna be going, most of the time, they're gonna be going home that day. Leverage with payers has been a little bit less. I mean, we did leverage to get some reimbursement per member from one of our local payers on a quality aspect because we see so many patients that would otherwise probably go to emergency room, be admitted, suck up costs. So I'll be happy to take any questions and Caitlin can help answer any questions that you may have. No, great. Thank you guys so much for that overview. It's very, very helpful. We're getting some good questions related to staffing and billing. So I think you hit on some of the staffing with the providers, but what does it look like in terms of support staff for them? So you're nursing, do you have MAs? And when you, you know, obviously you guys have really advanced and expanded. When you started this, kind of what was your thought process around the support staff and the team that you needed and then walk us through kind of how you progressed to where the expansion and where you are now? So when we first started, as Dr. Salenberger said, it was six bays. So we felt that was manageable with just one nurse and one MA who kind of acted also as a support person, I guess you'd say, like an administrative person, helped, you know, create the charts and do prior ops if needed, checking all that, all those boxes. But as that progressed, we brought in a second nurse to help manage the patients. And then from there, the MA then was really in the MA role. And then we hired a support administrative person just to run that aspect of it, answering the phone, because we had the phone number linked right to us. You know, primary cares were calling us saying, hey, we want to send this patient over. Is it appropriate? Can we give report? So they were answering the phone and doing the administrative work for that. And then the two nurses and then medical assistant were rooming the patients, taking care of the patients. Once we moved to the 14 bay, that's when that third nurse kind of came in. And then we were doing three nurses, one MA, and then continued to progress and get busier. So we added a second support person. So we have two support, like administrative people, one MA and three nurses in our Albany location. And that is, they're seeing about 40 plus patients a day. That's great. And that's very helpful. So I think one of the challenges you probably faced in starting this is, okay, what can I do with limited resources to get the support? So thinking on what you've learned, what would you tell another group in terms of a starting point for the staff that you must have, keeping that resource and budget in mind as you're getting ready to move forward? As you're getting started? Yeah, I would say you definitely need a nurse. You definitely need an MA. And then know that you're probably gonna have to grow it at some point. That it's going to eventually take off. And so you have to be open to hiring people as that volume increases on a steady basis. The other place where you need buy-in is from your imaging techs to know that they're gonna have to add on ECHOs or stress tests or CT scans. And so having a model in which they are bonused based on productivity or adding on cases is helpful in that situation. Jenny, I'm gonna jump in here really quick, adding onto that imaging. It's a popular question. Obviously, we're big fans of your program and we've often speak of it. And one of the reoccurring questions is always prior authorizations. How do you deal with the imaging and the insurance? So I'd love to hear more about that. So right now, most of the time, we do the imaging without prior auth and ask for forgiveness later. Most of the time, we are forgiven. And if you're not, you can usually get a physician on the phone on the other side and tell them, look, like your patient came to our office where we have an urgent care. You have to explain it. Like we have a cardiac urgent care. It's a unique situation. They walked in with chest pain. We did troponin. It was negative. And we did a CT scan, ruled them out and sent them home. And they never went into an emergency room. And so our CT scan that you're denying, the next time a patient of your insurer comes in here, do you want us to send that patient to the emergency room? And I'm 100% know that the cost is gonna be greater than the $350 you gave me for the CT scan. And so they mostly, oh yeah, I understand. But next time, make sure you ask beforehand. And then we go, okay, we'll do that. And then we keep doing the same thing. I love it. I love the yes, sorry, not please strategy. That's, you know, I like that. And so majority of the time, are you guys compensated for that? Yes, yes. Vast majority, vast majority. And especially with local payers, with local payers, right, now they all know and they don't really give any pushback on things that are coming out of that urgent care site. Yeah. And what about the bandwidth of your calling? So that's another reoccurring theme is we can barely handle business now. We never have enough docs. So how can we possibly ask them to do more? How did you get buy-in from your guys? Your team? A little bit, I like to describe it as the frog in the water, right? Like we started out with a frog in the water and the water was cool and everything was great. And then we certainly turned up the heat. Like if you put a cardiologist into an urgent care and they have their own, you know, our guys see 40 patients, 35 to 40 patients a day in their own office. And then there's another 40 patient urgent care clinic that, you know, people would just say, absolutely not. But then we slowly have adapted over time by adding advanced practitioners, by adding other physicians in so that the diffusion of responsibility as such or the diffusion of the patients as such that it doesn't add too much. I mean, it can be stressful and we try to rotate the docs in and out. And we also try to find other ways to make it easier in our docs. But, you know, in the end, our goal is to provide the best care to the community and to our patients. And this is a way to do that. And it certainly has been a boon for us and as part of our culture now, over time it just becomes a part of your culture. So that also helps everybody become more accepting. Awesome. I'm gonna ask another question before I let Jenny jump back in. I can see the administrators on the chat here, who we are about the finances, right? I'm assuming you're in the black seeing you keep opening more sites. That being said, how long was it obvious that you guys were, this was, you know, you were making money, not losing money on this? For 2014, we were in the red because the patient. So let me just say this part of a little bit of this though is it depends on how you track what the reimbursement is. If you're just tracking reimbursement as the labs and the patient visit that day, then you'd say, okay, we remained in the red up until probably about a year in before it went into the black. If you're able to track downstream testing associated with it, it's very different. But most people would say you can't really associate those two things. So you have to give it at least, and it depends, I would say at least a year to see enough of those visits to be able to justify the cost of the nurse, the MA, the space, the telemetry, the purchase of the telemetry, the purchase of the upfit of your location. That being said, truly, honestly, most patients who come in there have an active symptom. So most of the patients, even if they're not getting imaged that day are getting imaged in the near future. They're walking out of there with an order for a nuclear stress test, a PET scan, a CT scan, an echo somewhere in the near future so that your diagnostic and imaging revenue will go up to help also compensate for some of that. Yeah, that's very helpful. And I think there are a couple more questions in terms of the billing and how you're billing. Are you billing it as a normal office visit and then adding on each services? So within your, within the walk-in clinic, I'm assuming ECGs, potentially labs, things of that nature, are you adding those onto the E&M or what does that look like? Yeah, no, it's definitely billed as an E&M visit, usually level four, upwards of a level five. And the labs are just, are billed just as they would be if you're seeing a patient in your normal clinic. We're just billing it that way. So all is billed as an office visit. Right, I mean, to truly meet, I don't know how to put it, like an urgent care type scenario, you have to have certain hours, which is why we don't have the word urgent care and it doesn't say cardiac urgent care. It says enhanced cardiac access. So essentially it's just a very thorough acute office visit, which also, but has its pluses, right? It may mean there's not some sort of urgent care billing that you can do or special type of billing, but it also means that the patients don't have a large co-pay. So they're less likely to be upset about that. It's gonna be whatever the $50 they pay for their usual co-pay rather than the 500 if they visit an urgent care or an ER. So that was a good question because I think we're talking about urgent care models, however, knowing there are regulatory things that we have to be compliant with and maybe urgent care isn't the actual proper term and how, because there needs to be some differences. So I think talking through also, there's some questions about kind of your clinic hours and reminding people how many days you're open. And if you have a specific cutoff time of say five o'clock, what's the last time you see patients? Obviously, I'm sure there's variability there, but kind of talk through your access and what your hours appointment slot look like. Yeah, so we operate Monday through Friday, 8 a.m. to four. And then at four o'clock, we don't just shut our doors. So if a patient were to walk in at say 10 after four, we have what we call late check-in process where the front desk staff will check the patient in and the nursing staff will go out and assess the patient, get their history, why are you here? What are your symptoms? They'll do a set of vital signs and they'll get an EKG. They'll then present that to one of the providers and say, this is why this patient's here, what would you like to do? And sometimes a provider will just pop in and see them. Sometimes the provider will say, oh, it's just surgical clearance, let's have them come back tomorrow morning. Depending on what the patient's here for is where the plan of care will go. Sometimes it's just, we can't do much for you because testing at that point is wrapping up for the day and we do end up sending them to the ER. But it really depends on the patient's history, what they're here for and the provider and the nurse come up with a plan of care for the patient. But we did develop that earlier on in the process because we were seeing that patients were coming in later in the day and it kept getting later and later the busier we got. So we did develop that and that seemed to work out well. And the patients usually are pretty receptive to that. Yeah, I mean, our goal every day, we quote, take the last patient at four o'clock and then stop. And the goal is to have those patients out by five because mainly I don't wanna pay overtime to the nursing staff. But understand like you could create a model where you took, I mean, you could create an urgent care model where you took patients all afternoon and all evening. The problem is there's the amount of support staff because you have to have not just an advanced practitioner and a physician and a nurse who are willing to stay, but you also have to have a lab personnel who can still run labs because troponin is such a, or hyacinth troponin is such a key part of this. And then you have to have imaging staff because you might need an echo or a stress test or a CT scan. And so when we've looked at expansion of hours, it involves so much extra pay and extra staffing to keep those hours later that it just doesn't make financial sense. Same thing for the weekend, right? I could easily get an advanced practitioner to be in a office over the weekend to take urgents. I just can't pay the lab people, the techs. There aren't enough techs to support that. So the costs then I think become prohibitive. But our goal every day is last patient at four, try to triage everybody out by five. It doesn't always happen. Sometimes patients are here till 5.30 or later because there's other testing or we're waiting on a last minute lab or something like that. That's great. For me, how close in proximity geographically are you to your regular clinic? I mean, it's in the same floor. So when I say a cardiologist, so the cardiologists are there seeing their patients literally adjacent to where this is. It's on the same floor as the urgent care. So there's regular patients coming in and being checked in at the same as the urgent care patients are coming in. They're just going to sort of a separate little area. So if a patient, for example, because one of the questions is, you know, they're just not feeling well, is it, would they come to your clinic or would they come to the walk-in urgent clinic, a regular patient of the system? Right. So let's say I have an established patient of my practice who calls in and says, I'm short of breath. What the triage nurse is going to do is say, let me see, does Dr. Sullenberger have any open slots? They would put that patient into my open slot in my regular office. If there are no open slots in my regular office and none for like an APP open office slot, that patient would go to the ECA. And also the triage people know where the primary doctor is. So if I'm in Clifton Park, they're going to send it to the Clifton Park ECA. If I'm in Albany, they're going to send it to the Albany ECA. If the provider's in the, you know, covering the hospital and they call in, they're just going to say, they're not going to say, wait two days until your doctor's back in the office. They're going to say, come in and be seen today. Which is really, again, a real benefit to nobody. I worked here before we had an ECA and you never, you know, it's always painful to take add-on patients into your office, especially when they're not your patients. It's Dr. So-and-so's patient. And here is a way that Dr. So-and-so who's not available on vacation in the hospital, whatever, that their patients can be seen if they need to be seen urgently. Yeah, I think that's amazing. I think that's great. And I think that's one of the things, right, that you probably had to show to your internal cardiology peers that, hey, this is going to offset some of those disruptive appointments that occur during the day. And in terms of, there's a couple of questions asking for clarity around referrals. So the patients can, they can walk in or they can call or you can have a referring call, correct? And then is there some sort of process, as you mentioned, like through triage within the, within the clinic to say, yes, this is appropriate or you, what is that a schedule or nursing, just, just asking clarification around that? Yeah. So over the years we've built different models of, and presented it to our triage nurses as what's appropriate. So they, they have what they, we call an algorithm. So a patient calls in with X, you're going to put them here. You know, and a lot of the times it is in the ECA, you know, high blood pressure, chest pain, shortness of breath, palpitations. A lot of them are ending up in the ECA, but we did, we created algorithms for the nurses to follow. So it was easier for them when they have a patient on the phone of, all right, this is what their symptoms are. And this is where I need to put them. And, you know, Dr. Sullenberger was kind enough to kind of look through that and make sure from a provider standpoint that, that he agreed with that. So as far as referrals go from inside, you know, our own patients, that's how they're, they're triaged. Outside patients, it's kind of a mixed bag. They could just walk in. And you know, that's just the culture we created. You can just walk into our clinic and we are going to see you. We have patients that see our competitors in the local area that will walk into our practice because they can see us quicker than they can see them. And yeah, primary care is they sometimes will call, but you know, in the beginning they called a lot and they'd say, is this patient appropriate? Can I send this patient to you? Our answer 99% of the time was absolutely. And now it's just gotten to the point where they just send the patient. Right. The, the, the patients will call their primary to say, I'm having chest pain, or I had shortness of breath. And they'll say, don't come here, go to capital cardiology to be seen. They have a walk-in clinic because only all I'm going to do is send you over there. So don't waste your time coming here, which we're fine with. That's why we built this. So. That's great. You've created that culture of yes, which really solidifies your relationship with your referring physicians, but also within the community, which is showing up as you're seeing that increase in new patients to your, to your practice. So that's, that's wonderful. There's some questions in terms of, are most of your patients kind of same day complaints versus, Oh, I've been having chest pain for a week versus, you know, I'm sure that's a mixed bag. I'm sure you see it all, but any, any insights on that? Yeah. I mean, you know, how do I put it like of the patients? Cause everybody, right. Physicians and advanced pressure always complain about, Oh, this wasn't appropriate for this clinic. Right. But because you do see, right, you do see patients that are exactly the patient you wanted to see. It's, you know, the 50 year old with chest discomfort, who is worried, but they have a normal EKG and you scan them and you send them home with non-cardiac chest pain and a normal CTA and everything's great. Or a patient who's short of breath needs a dose of IV Bumex or IV Lasix and some labs to make sure their labs are okay. And then quick followup. But you also see patients who've had chest pain for months, who just decide on a Friday afternoon that this is the time they're going to come in and be seen. And we've gotten used to it. You know, it's, you know, you can't really account for human nature about why people decide this is the day I'm going to go to the doctor and show up at three 45 or four o'clock on a Friday afternoon. But in the end, I always say, you know, we're helping that person relieve their, and they become a new patient and they, you know, that we're able to do testing and other things that help relieve their anxiety about whatever is bothering them. So I can't give you a percentage on that, but it's, it happens. Yeah. Another quick question. So if you see the patient in your urgent care, do you follow up with that patient or are they just sent back into the practice? So if it's my patient going to the urgent care, I would follow up with it. If it's a new patient coming in and it's and it's seen by the advanced practitioner alone, they don't have a card staff with the cardiologist. They have it follow up with one of the cardiologists who's staffing the ECA that day. If I see the patient as a new patient, in addition to the advanced practitioner, even without the advanced practitioner, I'll have them follow up with me. Continuity of care. It's amazing. This is, this is great stuff. Yeah. I like to say like, you know, because over time it's become this mammoth thing. So I like to say, we really created a Frankenstein monster. It's an amalgam of cardiologists and advanced practitioners on nursing that can absorb literally on some days, if you look across all sites, almost 90 unscheduled patients a day of which a third, so 30 or 30 to 35 are going to be brand new patients to the practice and do it day after day. And there's not anywhere else that you could, you could do that to have that sort of way to contract and expand to pull in all of these new, or all these patient visits on an urgent basis, routinely day after day. First of all, you just scared away half the audience by saying 90 new patients a day. Okay. That's across all sites. That's across all sites. And that would be, that's usually, I'll tell you Mondays and Fridays. That's, that's the days. And especially if it's been a long weekend, the, the, the day after the long weekend, they're going to be a lot of people showing up. So day after super bowl, all those days. Yeah. But I think the, I think an important message is to say, this isn't where you started. This is where you are now. So folks grow into it, right? A hundred percent. You, you absolutely, you saw the graph. I mean, the first year, I think we saw, I don't, I think it was like 800 visits over seven months. So that's easy. I mean, that's not that big. It's only later that it really took off to become such a a large. And by that time we'd adapted to figure out it's not like it goes from zero to 14,000 visits. You don't start off running. You've got to walk first. Right. Yeah. And there's a couple, Oh, sorry, Anna. I was just going to comment about the eBay. I think that's amazing that you just went on eBay and found equipment. That's pretty cool. You got to find stuff cheap, right? I mean, we still use it. It actually lasted us a long time. Unbelievable. Yeah, that's great. It's resourceful for sure. A couple more questions to wrap up. So there's an interest in wondering if you have thought about expanding to do some virtual appointments within the clinic. Has there been any discussion or thought about around integrating some virtual work to supplement or increase access? Certainly during COVID, we looked at that and especially during COVID, we tried to figure out what to do to keep ECAs open when we had different absences in different areas. And could we iPad and do, and we did some of that. I have not thought about, I mean, I've thought about having a virtual virtual consult service separate than the ECA, but not integrating it into the ECA, I guess is how I'd put that. Great. And then what medications are you administrating or administering in the clinic? On hand, we have, you know, IV beta blockers. So you have your metoprol and then we have cardizem and digoxin and we have labetalol. And then for hypertension, we have hydralazine. We have Bumex, Lasix, IV potassium, IV magnesium. We've really tried to think of everything that we can treat in an outpatient setting and not have to send them to the hospital. And Amio. We have IV Amio. Adenosine. Like we give, we give Adenosine probably once, once or twice a week. We give Amio boluses, or I mean, to try to pop people back into sinus. Probably once every couple of weeks we give IV Amio. Another thing that we've sort of expanded and like, gosh, I wish I had Amio here. Why don't we start putting, you know, it wasn't that we started out with IV Amio. We we've started actually, we even once started a Milrinone infusion in the ECA. It was, it was quite a, quite a scene. It worked. And the guy didn't have to go in the hospital and we sent him home on Milrinone. He was somebody who needed chronic Milrinone and we just needed to start it and make sure he was going to tolerate it. So we did it, kept him all day, sent him home with chronic Milrinone. Yes. I can imagine that was quite a scene. And I think Lynn, just making sure. Yeah, I think we've addressed most of these questions in terms of billing considerations and absorbing that amount of new patients. And of course we can circle back to any of these and we do send out a summary and these will be recorded. I think a question that would be a couple of questions would be what were your biggest challenges, you know, looking back on these 10 years, what were some of those biggest challenges that you encountered and have been able to overcome? Just as an insights to others who are looking to start similar programs or models. I would say in the beginning, it was educating the staff. I spent a lot of time looking through doctor's schedules saying, Hey, why didn't you add this patient into the ECA? This would have been a perfect patient. And just trying to educate them and get them to understand what we did in the ECA. So I think that was definitely, I wouldn't say it's a challenge, but something you have to stay on top of. And you have to really, you know, it's routine for them to do what they always did. So changing that culture, you have to stay on them and keep educating and re-educating until they finally catch on and say, Oh, you know, now I can, I, now I know I can just do, you know, put them on through the ECA. And then I always say that having the physician buy-in is going to be really, really important. It puts staff a little bit in the middle when the physicians totally aren't on board with what you're doing in the ECA. You know, you have some that are and some that aren't, and some that are right in between. So having the physician buy-in is going to be really, really important. Yeah, I would, I would agree. I would say for the, those challenges, I think we are still always trying to adapt at how to best cover it. Because one of the, you know, one of the things that came out was like, well, why don't you just have a physician, you know, who's going to be at how to best cover it? Because one of the, you know, one of the things that came out was like, well, why don't you just have a physician there with no schedule? But the problem is there's not always going to be a, so if let's say it's a 20 visit day in the ECA rather than a average 40. Well, if my doctor usually sees 40 patients in their office and they only see 20 because they're covering the ECA, then I've, and I already have APPs there, then I've really reduced revenue rather than grown revenue. So trying to manage it where you have physicians having their own office schedule, but also being able to cover the ECA and how to best do that has been, has been one of the biggest challenges. And initially getting physician buy-in, I mean, getting other physicians to cover and understanding the importance of it. And it really just took time. It took time and feedback and their patients telling them, oh my God, I went there and it was great because they saw me and they made me feel better. And I went home and everything was great. I didn't have to go to the ER. So, so I would say those were definite challenges and remain challenges to us to this day. One other thing I would add is the image. One last quick question. I apologize, looking at the clock and it's a really good one because you guys have grown significantly at the same time, you're still growing your general practice. So all the, how do you keep up with all the new patient volume? Right. It feels like the math at some point isn't going to work anymore. Yeah. We're always hiring and I mean, we're always hiring and trying to expand and growing into new locations and growing our practice. And then like every other practice in every other specialty across the country, you have to have advanced practitioners because advanced practitioners are, are much easier to hire. They're, you know, it takes a little bit longer to train them and they don't have the necessarily this game skill set, but the future, there just aren't enough cardiologists aren't enough doctors to care for all the patients that are out there. So we have to find this collaborative method of working with advanced practitioners on an integrated basis. And, and, and so we're, you know, we're committed to that and try to teach that not everybody buys into that. Not every cardiologist is a hundred percent on board with it, but it's really the, the future I think, based on the amount of volume that's seen and the number of patients and the dearth of cardiologists and other types of subspecialists out there and primary care, to be frank. So, yeah. Wow. Well, this has been amazing. We are grateful to both of you guys for the last minute showing up for our members. This is, I could pick your brain for hours, honestly. But we re we, we are appreciative of your resourcefulness of your doing it on a Google sheet, you know, eBay, all these simple lessons that honestly just, you know, we, we get so caught up in the details and often we, we are our own worst enemy in building new programs. So this is a great lesson for our members. We also want to just remind everybody that this is hopefully just the beginning of a series of webinars about this subject matter. We have a paper coming out in January where Capital Cardiology Associates will be part of one of the case studies and a couple of other programs. And then February 13th, mark your calendars in the new year, we will have another program who was part of an integrated healthcare system. So we can see how that works. And I think the lesson for everybody is there's no one perfect model for a practice, right? It's really taking a little bit from all of our different members and figuring out what works best for them. And at the same time, just taking a risk. We're kind of forced to make hard decisions quicker now, right? So hopefully this can help people. Any other questions? We're happy, Jenny and I are here for you guys. We're happy to take it. We're happy to go back to Capital and ask them and to the rest of our, of our case studies. So we look forward to seeing you guys again in January and then again in February and happy holidays to everyone. Thank you. Thank you. You too. Thank you guys so much.

Capital Cardiology Associates

cardiac urgent care

walk-in clinic

New York

healthcare costs

non-invasive cardiology

emergency room

telemetry equipment

patient assessment