us today. I know people are getting on and joining us. We're so excited to continue this discussion around our kind of urgent care type models. And today we have a really great speaker and lots of really good information. I will, as people are joining, do some housekeeping, get everybody oriented. Next slide, please. You will see there are two buttons at the bottom of your screen. So the chat link, we will not be using that to interact, but you will find the link to access the slide deck here. If you have questions during the presentation, please submit those through the Q&A on the right. And we will have some time at the end of the presentation where you can submit and ask Dr. Gavin specific questions. Next slide. Next slide. So we started this journey recently as there's this need to understand how we can deliver kind of alternative methods to our urgent care type patients. So too sick for the office, but not quite sick enough for the ED. So Ann and I have been on a journey and the rest of the team to find what's working well. And there's a variety of models. So there's not one size fits all. It really depends on what you're trying to solve for and what your resources are. So we have found some organizations that are doing this really well and have learned a lot over some time and years of experience. And so we're bringing them straight to you, our members to learn. So we really hope that you take this time and do your research and learn from the various different programs pieces from all of them together. So we look forward to learning today. And next slide, please. If you will help me welcome our special guest, Dr. Michael Gavin. He's the director of the cardiac direct access unit at Beth Israel Deaconess Medical Center. And he's going to tell us about his wonderful program and the team that helped stand it up. So thank you so much, Dr. Gavin, for joining us today. Thanks for having me. All right. Let me share my slides. OK. That look OK there? Perfect. Perfect. OK. All right. So this is just a slightly modified version of a slide deck that I presented at the CD transform, which I spelled wrong on my title slide here. But back in the fall, it is a story of what at Beth Israel Deaconess Medical Center in Boston, a story of what's called the cardiac direct access unit. So it's one model that I had come up with back in 2016, actually, and launched the process, which I'll get through started earlier than that. But but it launched in 2016. So we've been in business for a number of years with a good amount of experience and evolution over that time period. And what I want to really get across is the two hypotheses that I had heading into this, along with others in the division who were supportive of it, are that as cardiologists and specialists within our field, that we're well positioned to actually optimize health care utilization. I think, you know, at that time, all the talk specialists are spending too much money. Specialists cost the system money, too much specialist activity. But I wanted to flip that around and say that actually, no, I mean, in these cases where patients are too sick for the office, but don't necessarily need to be in the hospital, that our specialization and knowledge set and risk tolerance can really aid in and better utilization. And then for those who do then ultimately need to go into the hospital to accelerate the care plan if we get to them first, rather than have them go through the emergency room. So the genesis of this is based on some data that my mentor and current clinical chief, Peter Zimmabom, had worked on back in 1998, actually. So dating back even before that. So when they looked at, along with our chief at the time, Mark Josephson, were very, I would say, annoyed by the fact that so much AFib ends up getting admitted to the hospital. We know a lot of our patients with AFib. People get very worried about AFib, how fast the rates are. And reflexively, our admission rate was 74% if you showed up in the ER in 1998 with atrial fibrillation. And so what they did, and this is Mark Josephson here, was get down in the emergency room, really, and work with the ED attendings, creating a protocol by which cardiology gets involved early. And if patients were adequately anticoagulated, they could be cardioverted in the emergency room. Anticoagulation, which at that time was really warfare, and then would be owned and kind of managed, initiated through cardiology. They'd get plugged in, and those who were unstable or couldn't be cardioverted would get admitted. But in the process, brought the atrial fibrillation admission rate down from 74% to 38%, and cost estimates are as follows. Problem is, when you are involved in an emergency room program like that, or really any of these focused initiatives, that when the protocol is over, the study group is gone, there's less focus on it. By the time that I started to look at some of this data in 2010 as a fellow, the admission rate had nearly doubled. So I'm going through my MPH during fellowship. I had an interest in this, basically the global concept of, are there patients who don't need to be admitted? And we know that there are. They end up on the floors. It's clear to us that there is a large group of patients who can be managed in kind of an intermediate setting. EDs had started to create observation units. Peter Smolovitz was one of the leaders here in our emergency room of that, along with Shemai Grossman. So big ED observation program. But interestingly, looking at with Bruce Landon, who's one of the health policy experts at the School of Public Health, what is the estimate? So how much money could you save in terms of health care costs? Well, the ED, actual ED costs are not that high. And there's a lot of talk about ED avoidance, but it's not so much the ED, it's just that the ED is a gateway to admission. So when you look at hospital care, 30% of overall health care costs. So we know that there's a group that shows up in the ED. We think we can kind of avoid the admission process and estimates really are one to two and a half percent of total health care spending could be avoided for these. And look at the groups, congestive heart failure, angina, chest pain. These are our patients. These are a lot of our patients who fall into this group of kind of what we might call ambulatory sensitive admissions. So we know that there is, I think, a financial argument. And again, I'm doing this, this is 2010 to 2013. ACA is hot off the presses. So there's a lot of focus on global payments and alternative payment models, which still is the case. And so through, with some help, this is Dwayne Pinto here, my fellowship director, Mark and Peter, the clinical leaders in the division encouraged me to really kind of push this through, paid for the MPH. And what we did was launch a pilot program. So put an emergency, put a cardiologist in the emergency room, moonlighting pay, 5 to 11 p.m. just on the weekdays with the goal really of identifying, identifying patients who could go home, right? So this is that period of time where the PCPs offices are closing, there's less access, you can't get in. That later afternoon, they're staying in the emergency room. What if we targeted that group, worked with the ER globally, not just AFib focused globally, all cases. And again, Monday to Friday, 6 to noon, ED would initiate the consults, right? So office to ED, ED to consultation program, and then, and we would consult from there and see what would happen. So what we did see is that in the red is ED observation. So pre and post. And we compared evening when we were there and the daytime when we weren't there, and also the weekends. So in the times we weren't there, there really wasn't much of a shift. But in the times where we were there in the evening period, there was increased utilization of ED based observation. Number of admissions therefore decreased. So we didn't send more people home necessarily, directly home, but we're able to support a higher level of care, at least with our guidance in the emergency room to avoid admissions. And so that again, was kind of proof of concept that really, if cardiologists can support that group of people, we can keep them out of the hospital. So what about if we just did it ourselves? And that was the genesis of the cardiac direct access unit. And we had to figure out though, how we were going to get this funded. And in and of itself, I think kind of functioning, functioning as a pure urgent care unit was not going to probably, probably would not pay the bills. All right. So what else could we do? And so three things, if we built an observation unit in the CDAC, okay. So we're seeing these urgent referrals. We can care for other types of patients, in particular, the post-procedural patients, which at that time were included CTOs, even high-risk PCIs, all the pacemakers, ICDs. As I'll get to later, there's been a genesis in that group. Who needs a bed overnight? Well, it's not those type of patients anymore. It's not even really PVIs anymore. It's structural cases largely. And some of the ICDs, some of the later cases in the lab, people who may have a bleeding complication. So there's still a role for decanting the floors of the post-procedural patients and creating backfill opportunity for higher level of care patients who are in need, who need to be transferred in. So we build the beds. We can mix from the patients that we have come through the urgent care center and also the post-procedural patients. And we're going to bring new patients into the network. And we get that now. Once people hear about, oh, I don't have to send my patient to the EDL call, people outside the network are willing to give a call and start to refer people in. The last aspect of it was, okay, so we're going to have a clinic space, you know, one doctor doing the urgent care part, but that's probably not going to, we want to leverage now the medical assistants that are in there. So we want to use that, the human capital that you need to run just the urgent part. So advanced heart failure at BI was really growing at that time. It's grown a lot now, doing upwards of 30 transplants a year. At the time, we didn't even have a transplant program. So growing advanced heart failure clinic, IV diuresis capacity in the unit. So that made sense to also house that in the space. So three real return on investment proposals. One, we have a new location for an expanding clinic that made sense in an urgent care unit because they're high utilizers, these type of patients, IV diuresis, overnight diuresis, and ability to decant some of the post-procedural care on the floor, get inpatient level of care patients into those beds who generate a much higher margin than those post-procedural patients. So again, we launched in 2016. The kind of core group was our associate chief nurse. Peter, again, was our clinical chief. Sarah Moravec was the head of what was at the time called innovations and improvements. So kind of your project management group within the hospital. So that was where she played a role and supported it because it was a novel care model. You need a strong project manager. She was extremely strong, has moved on to bigger and better things. And at the time, it was our CAO of the Department of Medicine, who's now the president of Baystate Hospital, Sam Skouras. So people who are kind of on the rise, but really was fundamentally within, for us, the Department of Medicine. This is what was built. I'll show you some pictures. Five exam rooms. It's a small space, but we took what we could get. Small space, five exam rooms, some workspace for the physicians, a very small waiting area. At the time, when we built it, a stress testing space in the unit, so echo and stress, was kind of underutilized. That space was better utilized with more exam rooms. So we have an extra exam room there now. And then six observation bays and an infusion room. So again, confines are not, get the spotlight on here, are not generous, but we make do with what we have. So small waiting room. The stress testing space, as I said, has been converted into an exam room. Down one hallway to the left is your exam rooms. Down one hall, down the same hallway to the right, centralized nursing unit, six bays, three walls and a curtain, and then the infusion space. So what do we see? A little bit of everything. So a lot of AFib, chest discomfort, and I'll go through a little bit on how we parse out, triage out what comes to us, what needs to go in an ambulance, 911, ACLS to the ER, a lot of heart failure, complications of device implants. So people who are coming back a day or two after their device implant, concerns about the generator site, vascular complications, they come back, call in, groin swollen. So these are patients that come direct, we get the calls. So it serves our cardiology group quite well, because none of us want to send those patients to the ER. We just want to get them in and get seen. And so the CDAC serves that purpose. And our vascular medicine group has worked with radiology. DVTs was a real headache for them. They identify a DVT in radiology, couldn't get a hold of the referring. What do they do? Send to the ER. We give them an alternative route. DVT gets sent to us if they can't get a hold of the referring. So the overall process looks like this. It's a direct phone call. So I'm holding the phone when I'm working there. There's a nurse coordinator as well as support. So if I'm in a room, she'll have it. I get the word out to primary care groups, both onsite and offsite. And it's really expanded beyond that. So we get a lot of patients from GI, people going into AFib, having bradycardia after colonoscopies, they don't want to send to the ER, but they aren't comfortable sending home. We get people sent from preoperative testing who were driving two hours from two states away for their high risk surgery, which as we all know, it's always in two days time and they show up and they have an abnormal EKG and are telling them they have chest pain. And so they're not willing to clear them, but they don't want to send them back and cancel the case. It's a cancer operation, those types of things. So we serve that group. And then our cardiology group, and it's about 50-50. So really about half the patients are our own. So people calling into our nurses, calling into our what we call heart line, which is our post discharge call line for patients who are just in the hospital. And they're either seen that same day or we can schedule into access slots, we call them. So this access group serves two purposes. If I get a call and somebody doesn't need to be seen the same day, they can be seen tomorrow, the next day, fine, we use it. But it also helps our call center. So average time booking out is at least 30 days for a new visit. So anytime referring needs an urgent visit, they're not always urgent, but there's consideration, many of them are. We've now provided five additional outpatient new cardiology slots a day that are scheduled by the call center. So helps our overall access, helps that group that is going to end up in the ER, and helps our colleagues across the institution in various areas. And what do we see? So the first year I took a look at this, we did a deep dive in terms of the diagnoses and where patients went. So if you look here, about 14% of patients are admitted, and these are only people who are seen on the same day. So this is kind of that where you consider the most urgent, the ER group. Call, seen same day. 25% stay overnight, but 60% actually go home. So these are patients, again, who would otherwise probably have gone to, by all accounts, would have gone to the emergency room. 60% are sent directly home after speaking with the cardiologist. How does that compare? At the time, I looked at some national and local norms or comparators. These are unmatched controls. I'm not, certainly not to say that this is an absolutely fair comparison, but I think directionally gives you some sense, and I think experientially we believe this to be true. So chest pain in the CDAC, 46% go to observation or get admitted, 71% among that, among our internal controls with a large observation unit. CHF, 33% stay overnight. So it's a lot of diuretic adjustments, same day IV diuretics versus 77% admission nationally. And AFib, much, much lower. We almost never keep people overnight for AFib because we can usually get them set up for cardioversion next day, day after, within a week, whatever the case may be. So sure, I mean, this is not the same exact population, but I think you get a sense that we're at least accomplishing the intended goal. And those numbers really have persisted. So this was presented at ACC just this year. So now looking over six years, we have 9,300 patients who were seen same day, on average about six a day, and these are just the same day. And then here's the total numbers, but we're still seeing about the same thing, 27% going to observation, 71% overall are going home. So most of the patients were still able to get home, again, 50-50, roughly, cardiology, PCP. Here's the rest of the things that we talked about, other urgent cares, specialist clinics, pre-op testing, GI, all of that. So what about satisfaction? We've looked at that using our PRESS-GAINI scores. Here's 2019 through 2024 overall satisfaction. What I wanted to kind of get a sense of is CDAC's in orange, urgent care in gray, emergency department in blue. So people like urgent care, it's not surprising, I think we would all agree with that, would rather go to an urgent care than an ER, But they'd rather go to the CDAC than even an urgent care. So those are the overall satisfaction numbers from Press Ganey. And then waiting time, kind of similar. The amount of time that even in urgent care versus us, you're getting direct. I mean, you walk through the door, you may wait a little bit, but you're seeing the cardiologist first thing, right out of the gate. And then if you need to get it, we'll go through the care model. If you go to observation, then we have a nurse practitioner working in the observation unit. So admission avoidance. Financially, right, you want to justify a unit like this. So two arguments there, and I'm going to go through some of the numbers. The benefits, as we talked about, for alternative payment contracts. So admission avoidance saves the global construct money. But simultaneously, you have that backfill opportunity. So you've kept that bed open. So even in the fee-for-service model, that bed is going to get filled. Most hospitals, at least ours, is running over capacity. That bed's going to get filled, and so you're generating revenue from that bed. And then, what about readmission? Financial penalties associated with readmission, those rates have been going down across the country. But we kind of just asked a basic question. This is not of rigorous science, but among urgent same-day referrals within 30 days of discharge. So this, we just looked at people who were discharged from BIDMC within 30 days that seemed the same day. Came up with 971 of those, and of the 971, 56% go home, 9% to observation, only 35% are readmitted. And so it doesn't really, it actually, if you look at your Medicare readmission numbers to move that penalty, takes very few patients. That's partly because very few people are considered in, you know, we're quote-unquote eligible for the analysis. But if you catch a few of those, and we're looking at 8.2 a month, which is far exceeds kind of the overall eligible, if you just shift a few, you can have an impact. And our numbers have gone down. We're still not best in the country, but they've gone down. How much of that's from CDAC, hard to say, but it's at least thought-provoking. Okay, so finances. I've hinted at this. Obviously, it's a huge part of either building and maintaining a care model like this. And so, well, how did it look? These are margins. So this is true, this is real dollars, cost, so revenue over cost. And so the net revenue on your outpatients is not huge, but there is some net revenue on the observation. If, however, a patient is leveled as inpatient, I'll come around to how that is. Now, this is a comment, so this is an outpatient space. But during the public health emergency and the pandemic, alternative care spaces, at least in Massachusetts, are able to be used for inpatient. And even currently, because of capacity crises across the state and in our region, the same thing is in effect. So various states are going to differ on that. But as capacity crunches exist in the hospital, we've been able to admit and care for inpatient level of care. So if you look at inpatients, the revenue on them is about 5x, 5 to 6x. So if somebody is inpatient level of care, you definitely want to be able to bill for that, because there is a significant opportunity loss if they level, keep them as observation. But we have to, but you know, you got to abide within the rules of the space. And again, we were built as an outpatient space. The other comment that I'll make about that, I'm sure there'll be some questions, is again, if you think about the backfill, even if you had somebody who would level as inpatient in the CDAC, if the house is full and you kept the bed open upstairs, you've gotten your margin on the observation patient, and you're still getting your margin on the inpatient who would have still been at the outside hospital or sitting in the ER and not gotten in. So even if the level of care has to be leveled down to observation, so long as you're running at capacity and you're running at capacity and you're freeing up an inpatient bed, you're still making money. And it's still favorable for the hospital. From a cost perspective, the overhead really is a bit of a challenge. And again, you're going to take the space that you can get, space that we got, we got six beds, but you always need two nurses. So if you're running 24 hours, you always need two nurses. You can't have less than two nurses. One needs to go to the bathroom, take a break. You can't have one nurse alone. So always need two nurses and an APP. So the way we staff it is one APP during the day who manages the six beds. And they're actually quite busy because there's so much turnover. The structural patients, the post-tabbers coming in, she's got to get those all, he or she gets those all out in the morning. And then I'm coming down all day saying, I got this one, I got this one. And we're trying to turn everybody over quickly and actively manage these six beds to really fully utilize them. So it seems like a few number of patients for an APP for one person, but it's very, very busy because it's not really six. It's often more than that with all the turnover. And similarly with the nurses. So in the afternoon where things get busy, we are often at three nurses for some overlap period. But that overhead is fixed. If we had seven beds, it'd be the same. So that's something that you want to keep in mind as far as the observation care part of it. If you can get people home and then come back for their outpatient procedure, that's always the goal. And that's why having cardiologists who know the schedulers in the cath lab, who understand those processes, who feel comfortable sending a patient home who they've never met before, because now they at least have our number and saying, yeah, I know you're still going a little bit fast, but started some topical and you're going to come back on, this is Tuesday. You're going to come back on Thursday. I've already got you a spot for a TE cardioversion. That's better because if you look at the average margin or rather these are payments, just payments, average outpatient cardioversion payment, $1,321. And you know, you add an echo into that. You're looking at 2000. If you look at the total net revenue on these, of course, don't include the costs, but revenue and observation numbers are actually pretty similar. This, this does include the cost, the overhead and the nursing costs, but it is advantageous. It's much more advantageous to not have these things bundled into an outpatient observation payment, because ultimately the payers just decide what they're going to pay. We all think of it as, I've always thought about, you hear about obs a la carte, obs a la carte, people are getting charged. It doesn't, that's not the way the payments come through. For some of the pharmacy charges that may be, we haven't heard from any patients saying that they've gotten killed on their bills and we see what's coming in. The payers just roll it all up and spit out a number, kind of no matter what you did. So it is still better to try and get the patients to outpatient observation, rather than outpatient procedure. Okay. So we strive to keep everything in an ambulatory setting, but the CDAC is creating new observation revenue, helping offload the ER, which is already overcrowded. Inpatient needs are identified. Patients go up. Care plan is accelerated. They're happy. But as I said, a number of times, now here just graphically, we can see it. We're here at BI, we call it code help. Code help, constantly it's triggered by the number of patients waiting in an emergency, in the emergency room, and the number of patients waiting for beds. So you have criteria crosses, but you have to have that for DPH. You have your criteria crosses the threshold, code help. So basically living at code help, even having built a brand new cardiology tower. And so the beds are in high demand. Okay. And we want to get patients in who need a transplant. We don't want a patient with rapid AFib in that bed who we could easily manage in the CDAC. And so I would encourage if you're thinking about this at your center, work with your revenue office and get some calculation of this. And so what we did was look at average contribution margin per cardiology discharge over the length of stay. So you get a sense of dollars per day that the bed is worth, which is totally different from what you're going to see in your budgeting software. Because there's just a room and board cost assigned to that bed. That's all budgeting. This is real dollars. So you want to get the actual revenue, net revenue, which those numbers are available. And then you say, okay, how many bed days are we saving? And 100% backfill, that's not going to, that's not reality. But you might say 20% of the days that we're keeping people downstairs, there's some lost in ether, annual margin, about $850 to $1 million. So that figure, while it doesn't go into our cost center, is something that I do track. And I think it's very important for the overall financial modeling and health of these type of units. So the problem we're running into now, so you get into some of the challenges and leave plenty of time for questions. Challenges are, again, we are an outpatient licensed unit. Capacity crisis have allowed us to care for these types of patients. I think they're the perfect patient. This is the new overnight patient. Most of the left atrial appendage occlusions are going home same day, but the vast majority, really all of our TAVRs, I know there's some same day discharge TAVR programs, but ours are really staying, you'd expect a standard TAVR stays one night. Same with the MitraClips edge to edge repair. The complex PCIs, the pacemakers, the ICDs, the PVIs, there's still some issues like case, frail patient, sending them home after anesthesia, not ideal. So these patients are still coming to some extent, but this is a lot of what we get over the course of the week. And I'm hoping, you know, this is a bigger topic, of course, and the implications of moving off of a non-inpatient only procedure categorization as far as the cost, as far as the revenue for TAVR. But we hope to be able to keep those patients, whether it's through a special program, applying to the DPH, which we'll ask for if the current status ends, to kind of looking at opportunities there for more creative thinking about what we can keep, because it's safe, because of the right patients, because it's good for patient care. They get through quickly, they have close care, nurse practitioners are used to it. But we'll see, that does present a challenge, because if you put a TAVR in an OBS unit and bill observation care, you lose the whole bill, you'll get zero dollars. So it has to be inpatient. Now, MedAxiom has talked about, has addressed this as well, and Jenny had brought this to me, kind of looking at alternative spaces for watchmans using cath lab holding areas, things like that. So this is actively being looked at, and we're going to continue to look at that. So this is active work, and something that I've certainly been keeping in touch with the MedAxiom group on, because nationally, how we care for these patients, where they spend their overnight is a big issue that we all need to think about. So this is, as I said, the capacity crunch, the DPH guidance that has allowed us to operate at least through April, and we'll see, I think, politically, with the capacity problems, there's hopefully an opportunity for interest in special applications. We tried this before, but it was years ago. I think the world, that was pre-COVID, the world is much different. There's a summary. We talked about one, two, and three. Talk a little bit about number four now. So I do two shifts a month. We have a different doctor every day, and then we also have a moonlighter. So there's somebody from 5 to 11, there's moonlighting pay, and that doctor sees a patient at 5.30, a patient at 6.30, anything that comes in late in the afternoon, they staff, patients coming in to the observation unit from other sources, and then they go to the floors and see patients with, we have residents and fellows, either consults in the ER or patients who are admitted to the floor to get a care plan in place before the next day. So we have that job, but when you're working, it is very, very busy because you're doing everything. You know, you're seeing the scheduled patients, you're taking referrals, people are, you're kind of making, you're trying to get care through, so you're calling the director of the stress lab, I'm calling the director of the CAP lab, and our nurse coordinator knows all these folks too, so we kind of, we certainly team up on it, but we're pushing to get people through quickly and get them the tests that they need quickly. I see a patient, I pass off to the APP, I go back, I see more patients, keeping an eye on the beds. There's a lot happening, not all of it revenue generating. So I thought about this, I said, all right, let's kind of look at a couple of different things. I know everybody's a bit different as far as what their schedules are. A CDAC day, which is scheduled from 8 to 5, but by the time you're done with all your documentation, pass off, everything, you know, a really super busy day, really busy day. So you discharge three, but you got nine new patients, three of whom go to OBS, so there's three new admissions, three discharges, but you're still looking at only about 34 RVUs for that amount of work, for that amount of work, and it takes all of that 12 hours. Rest for clinic, it's steady, you schedule patients, some of them are double booked, you're doing better, and ECHO, which I do as well, that's the easiest of the three, that's only, you know, whatever, everybody's different, I could say arbitrarily, let's call it seven hours, and you're looking at 40 RVUs. So this is a challenge, I mean, it's something that culturally you need to stay ahead of, and it takes time for it to gather steam, and in that, I mean, people work in it, and yes, it's busy, but then they're in their outpatient clinic, and somebody's sick, they don't have to send them to the ER, they can call their colleague, and just arrange for transfer, get the care, moving along, they have a place that they can send patients to OBS, so you're able to care for your patients in a way that you really want to, that you think is the best care, and similarly, you're not in clinic, your nurse is taking calls about chest pain, or volume overload, you know the patient, they're probably wet, you can just tell your nurse, yep, let's send them over to CDAC, and those arrangements can be made. So the advantage for the patients and your own practice is really there. A lot of the doctors are, don't have outpatient practices that, you know, maybe have research careers, but it's part of the mission, it's part of the culture of the group, that everybody appreciates, not just within cardiology, but again, the specialists, other areas, the hospital, and so I think recognizing that appreciation, getting people to buy in, and rotating through the staff to some extent, people do it for a number of years, you get some new faculty in, they do it for five years, they will bond, so you do have to consider that. But cultural buy-in is big for us, and they have, they really have, and people recognize why this is a special place. So those are the conclusions, but I, ultimately, the big one is, I think, when you think about where we stand, we definitely are part of the solution for overcrowding, solution for overspending, and really creating a new pathway for access that wouldn't exist otherwise, can't accommodate in our clinic space. So some of the nurses that started in 16 are still there, Suzanne's still there, Lynn's still our nurse specialist, a few are not, Diane's still here, people like working there, we have a very strong group with Liz Morrissey, who's our current nurse director, but across the division, really, Rob Gersten is our chief, and Peter, the co-chiefs, really, they, if everybody's on board, it's successful. So I had my full screen up, so I'm gonna pull out now, and let's see, so we have plenty of time for questions. Yeah, that was, I think the program's amazing. It's definitely a learning experience, right? So, looking back, we keep talking about this, everybody complains, and that complain is, they're concerned about the bandwidth of their existing doctors, right? They, like everywhere around the United States, there just aren't enough people, and there's too many patients. Every time we talk about these models, because they, everybody wants to do them, but their first, kind of, no, their roadblock is, we just don't have bandwidth, our doctors can't do it. How do you, how do you, how do you stop? You said it's busy, and as you, and as you demonstrated, doing a day in the echo lab versus a day in the CDAC doesn't, and if you're an RVU-based model, it doesn't, it doesn't, it doesn't balance, right? How do you guys figure that out? Yeah, so the, you spread it out, so you think if the group is big enough, again, one of the advantages that we have is that there are some people who, this is their clinical, part of their clinical footprint, so they're primarily on the research side, or maybe just doing imaging. So this is part of their clinical footprint. There are more readers in the raw record days, there's some access there, but it's really spreading it out. So I do two, most people are just do, you'll do one day a month. Some are one day every other month, some are more. And so on a busy day, I mean, I can essentially do what I do in clinic, but it also provides me, the reason I keep doing it, okay, yeah, it's a little bit of an RVU disadvantage, but on the other hand, I can't get patients into my own clinic. All the referrals are coming in and I don't have a place to put them. So my days there, the two days, I use my access slots for all the referrals that I'm trying to get through. So it becomes a pop-off valve actually for your own practice when you're in there. And similarly, if I have a patient who I know is kind of slowly decompensating and I need to get him in, I know it's going to be a busy office visit. Well, I could see two revisits in the office and I could bring this one into the CDAC and kind of get them the care that they need. So there is, I think the two keys are spreading it out. The buy-in that there is the value, and we have a small stipend that goes for the day, or actually the way we do it is we overvalue the RVU slightly. We're just trying this this year, is over the value the RVU is generated in the CDAC slightly at your end of the year balance sheet. And the way we do that is for us and some cost sharing with the hospital, because we know what our revenue is. So understanding the net revenue of the unit, then you make an argument for some funds flow that allows you to overvalue the RVUs. And that's kind of the way we're trying to do it this year. Is it still better to read a day of echoes? Well, sure, but we don't have enough access and we're helping our own access. We're helping the group and we're helping bring patients in from places that we wouldn't have otherwise. And so I think leadership then also needs to recognize that there is that the downstream that is created is very real, but you wanna track that. I mean, you wanna have a good sense of all of that and financially model it in a way that you can then bring a portion of that back to the physicians. Yeah, that's an excellent point. The data is critical, right? And being able to leverage, use it as leverage. And really quick, just as an operations person. So if you see a patient that instead of going to the ED comes to you, you've never seen before, are now you charged with following that patient forever? Or do you just, they see anybody in the clinic now? Like who owns that patient now? Yeah, so for me, I will own them. Depending. So a lot of them I'll see, they may not need me, they may need EDP or something like that, where it's a really focused question. And then I'll try to leverage other sources for the specialized vascular medicine, cardio-onc. So there's some ability to decant that way. But that's because I have a clinic. Again, 50% of the doctors don't have a clinic. So they go back into the pool. It's get the visit done, get the patient stabilized, NP transitional visit, and then ultimately end up in somebody's continuity panel if they need it. You'd be surprised though too, a lot of these patients don't, they're there, it's low risk chest pain, but the PCP was concerned, set up a stress test, stress test happens, you get the results, you're done. So there is a good bit of one and done that comes through the space too. Okay. Great. Oh, sorry, we just had a question about APPs helping in the CDAC. And I know you do have APPs, but maybe you can expand on that a bit and kind of where you're getting them, like what kind of background you're looking for? Because obviously with the fast pace and the acute of these patients, you need some experienced APPs and nurses. So can you expand on that a bit? Yeah. So the nurses really come from within cardiology. So these are cardiology nurses. And from an APP perspective, I'm the medical director for our overarching APP, really inpatient program. But the way our APP program is structured right now is that there's the outpatient APPs that kind of are doing their thing. There's the EP APPs who are doing the device interrogations in some outpatient clinic and doing kind of their own thing. But then there's the largest group which rotates between three spaces. They do inpatient. So we have an 18 patient inpatient service. And then we have the cath lab, which is split. So it's two cath labs actually in two different buildings. And they spend, and it's a day. So they're either on inpatient, they're on cath lab or they're in the CDAC. The group rotates. And so they're week to week. I'm not exactly sure how they do it. Like if one week they're kind of a CDAC week or it's a couple of days of cath lab, a day of CDAC. But that's how we do it. They rotate. So they're part of our core cardiology APP program. And similarly with nurses, these are largely nurses who have some cardiology experience or med surg experience who wanna get in enough to be interested in cardiology. Actually when we opened, about half the crew were older CCU nurses who were kind of transitioning out of the CCU lifestyle. So we still have a few of those. So that's, I hope that answers that question. But the APPs rotate through. The question has been, if we were to scale and see twice as many patients, is that enough to justify then having an APP, two APPs? One helping on the outpatient side. And I think the finances of that are doable. You need enough patients though. And so I don't think we're quite there. And part of that is we gotta keep the floodgates closed a little because you can't see everything that's gonna go to the ER. So it has to be somewhat selective. But we could titrate that, but it's hard to titrate before you know you have the resources. So I think we have a good balance right now. So- I guess that's the- Sorry, Jenny, go. Go for it. Sorry about so many questions. So please go. So expanding on that a little bit more, what is, how are you differentiating your roles, the physician and the APPs? Are they seeing the patients before you? Are they functioning independently? More driven on certain patient types? Or how are you guys working together to manage the patients coming through? So it's really a kind of a distinct group. So the way it works concretely is I show up, I get the pass off from the night before, I have anywhere up to six patients. Sometimes if it's a post-have or patient, I'm not gonna see them structural, we'll see them in discharge. But all right, let's say I have four patients. So between eight and 9.30 or 8.30 and 9.30, I round with the APP like you would on inpatient floor. On those four patients have a plan for the day. Then I go start seeing the first access patients at 9.30. So there's always a 9.30 patient. And then you kind of start down there, phone calls start coming in. Check back periodically over the course of the day on the plans if they need it. Otherwise just get people discharged or actually check back in at the end of the day if somebody's staying another day. I see a patient though comes in, heart failure, I wanna send them down, put them on a LASIK strip overnight and here's the plan. So I see them in the clinic, walk down the hall, say I got a patient for you, here's a story. And then they take it from there. So all the orders are going in, they may gather additional information that I missed in the visit. And then again, I'm looping back before I leave to run the observation unit. But they're functioning independently really throughout the day as a first contact for those patients. How long did it take to socialize this program, right? Before it became like common knowledge to the ED and to primary care and to folks outside your system that you guys were operational and you could see it picking up the momentum, right? Probably three years before it was ingrained in the lexicon and kind of just accepted that it was there. I think both, be aware that it's there, it still happens all the time, right? Because PCPs in the community, especially these groups that are not BI on campus groups, even on campus, the primary care group, there's so much transition and changeover that I'll get a call from a PCP at HVMA or Atrius Healthcare, which is the Optum group, not us, I mean, it's the Optum group, they admit to our hospital, but they're on Norwood, which is 20 minutes away. Is this the CDAC? And somebody told them, a cardiologist who they tried to call, one of their cardiologists said, no, call the CDAC. So it's funny how, I mean, I think the core people spread the word outward to the PCPs, but I think internally on campus, after probably about that three-year timeframe, everybody knew it was there, and we've evolved over that period of time. And probably that same timeframe, three to four years before the group of cardiologists, nobody can live without it now. I mean, if the unit were to go away, our practices, it would be such a strain on our practice that I think everybody knows its value, so it takes a little time to understand that, which gets back to the staffing part. But getting the word out, and I'd say, getting the word out to the PCPs is probably the hardest part, but once they hear about it from, who knows, from somebody, then they're like, well, wait a second, I just called, and my patient would trust me, and I'm, dude, they're just coming to you? Yeah, they are, and so then you get more calls. So there's, you know, there is that part of it. And those PCP practices sometimes are in the MGB system, they're not in the BI system. That's a win-win. Yeah. When they're with the competition, absolutely. And wait, you mentioned Moonlighters. Are the Moonlighters you guys, or is that a separate pool of doctors that you pull in from the outside? Who are your Moonlighters? They're us, so again, I mean, would that, something like that work in a private practice model? Probably not. It works in a larger academic model for the evening part, because, you know, again, there are younger attendings, there are people who are coming on who are still, we're not paid, you know, who are paid the usual academic salary, which isn't great, and, but it allows them to generate some more money. And again, there's all this stuff that happens in the hospital too, like we just shifted to the residents admitting direct from the ED. So prior to this year, patients, while they're in the walls of the ED, were cared for by the ED, no matter whether they were boarding for two days or, you know, there for two hours. So moved to residents admitting those patients up front. So now there's this pressure of, well, who's going to see this patient? I admitted them at five, you know, four o'clock, who's staffing them with me at seven o'clock? And so we have an answer for that. The EKG volume started getting out of control. We have an answer for that. We shifted 50 EKGs over to the person who's working at the night. So it's really nice to have a bit of a pop-off valve for the day-to-day, you know, needs of the division. So do you ever feel like you have to defend it? I think probably you've established yourself in the value now, as you've said, but in the early days, did you have to defend and kind of protect your territory from a leadership say, do we still want to keep this running? Did you have any of those conversations? It never had gotten to that point, honestly. I think everybody, because the leadership within my division believed in it and you also, there's this phenomenon too, right? Where the president's calling you to say, hey, I got this call from whoever, can you see him? Or the development office, we get a lot of calls from there. Hey, we've got a call, can you get him in? So it's very, I mean, I think the access to see a cardiologist is, not to say that that in any way justifies itself, you still have to have the financial argument, but the anecdotes are pretty widespread as to its benefit. And so I think it's helpful to, that's been good. It doesn't hurt, that's for sure, when the donors are coming to you, right? Yeah, that's right. And so we're able to, exactly. So we're able to serve the needs of the kind of people who just need to get in quickly and without triple booking your clinic. So that's where, again, kind of this, everybody's busy, but it does decant some of what gets layered on to a different place, which is helpful. But I've been, I think if you're gonna start with something like this, and I was a brand new attending at the time, so I had more time, but it's been helpful. I mean, I just have learned a ton about hospital operations and you wanna keep your ear to the ground and understand how they think and get your financial modeling in place early because I'm telling you, there's two different things that happen. We meet on our monthly ops meeting and I'm getting what's coming through. It was Kaufman Hall, now it's called something else. And I'm seeing what's coming through on the budgeting side. And it doesn't, and then we went to Epic. And so numbers don't always match up. So I think making sure that you have a true revenue, contribution margin analysis that you can, you can stand by is helpful. It's not the, because then I can pull those slides up. They don't really, I kind of send them out when I get this, but it's there. You remind people beyond just the standard hospital budgeting practices. Because those are all charges and, you know, key statistics and all the other stuff. And that's helpful, but it's nice to have both because it's a complex financial model. It makes no sense, be honest. That's right. But we acknowledge that. So in hindsight, like looking back, this is an amazing journey. And again, it's impressive. We met in December with private practice and now hospital-based. So it's good to see the comparison, right? But now if you could, looking back, what did you learn? Like what's the biggest lesson? If you could do it all over, the one thing you would not do or the one thing you would definitely have pushed harder for, right? I think in retrospect, scaling it probably, we just didn't have a choice. The fixed overhead costs of the space limited us. Like, you know, so we could have gone up 20% probably on beds and exam rooms without any increase in staffing costs because our ratios with the nurses are better than the floors. So, but we were kind of restricted in that. So I think kind of, if you have the space, you want to get that right. You don't want to overdo it, but you want to get it right. The biggest thing that I've learned really is the world of observation, you know, versus inpatient and kind of how to operate in that and what those financial models look like. But you're fixed, like, you know, we weren't looking to add beds. To say you're going to add beds, nobody's going to add six beds. They're going to build a new tower, right? So, I mean, you could add six, but the inpatient checklist for an inpatient bed is very, the cost is very high because what's required is significant, at least, you know, for our DPH. So we want it to be what it was, but you start to realize pretty quickly what the challenges of that are, you know, being in an ambulatory environment from prior authorization perspectives and things like that. But I've just learned a lot about it and how to, you know, how to overcome it. And then I think Rishi Wadhara, who works in the union, you know, writes a lot in terms of health outcomes. He keeps pointing out, and he's right, he's like, I focus on the urgent part of it. Our patients don't have to go to the ER, we're keeping them out of the hospital, and the patients love that. But he's saying, you've just added five, six, you know, new inpatient slots a day that just didn't exist and you can't get them in in any other place. So from an access perspective, it's huge, and it is. And I just kind of see those as, all right, they're going to be there, I'm going to see them, focusing on the higher level stuff. But even for my own guy, I see it with my own clinic. Not places to put people, but that's my, you know, those two days a month I have is my admin knows, that's my access time. Want to wrap it up, Johnny, for us? Yeah, so just making sure we didn't have any other questions. So I really thank you for your time today, Dr. Gavin. This is very, it's very exciting, and we appreciate you coming and sharing all you've learned over the last several years. So thank you so much for that. And again, if anybody has other questions, please feel free to reach out to us. We're happy to connect and continue to watch as we learn. We will continue to have webinars and share our learnings with you, our organizations and members. And please let us know if we can do anything to help you. Have a great day. Congratulations, Dr. Gavin. And I'm happy to talk to anybody about it. I mean, I would like to see this spread. It's not, so I think there's a lot of experience. I'm passionate about it. Thank you. We appreciate it. Thank you so much. All right.

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