Good afternoon, welcome to everybody to our webinar this afternoon related to structural heart program opportunities and a walkthrough of a recent survey. I'm going to give it a couple minutes we have a pretty high number of attendees. And so I'm just going to give it not even a call, like another 30 seconds and then we'll go ahead and get started. All right, well I'm actually going to do the very first thing I'm going to do is direct you all to the chat, where in there you will see a link that will allow you to download these slides, if you're interested. And then in addition to that, this actually is a webinar version of a full report that we just downloaded or published onto our website. So if you go to medaxium.com and look for the structural heart survey report, you will see that and that's a full PDF with quite a bit more narrative related to the findings. So with that, we'll go ahead and get started. I'm Ginger Beesbrock, I'm the EVP of care transformation with MedAxium, thrilled with your interest in this topic, which tells us we hit a good one with the number of people that were signed up for this webinar, as well as the opportunity to understand what's happening in the space. And so as we get into this today, I'm going to start with a stay, structural heart, TAVR, care is complex and requires successful care coordination, relies on a lot of people, a lot of touch points, and a lot of care coordination for these patients. And so with that, we put the survey together at the end of last fall into early winter, with our goal to better understand staffing trends, coverage needs, program challenges, and opportunities for growth, or what are you all thinking, or what are you all experiencing related to your structural heart programs, and then we'll break it into specific portions of your programs. But what we start with the reality or your reality, this is not complex, or this is complex, and there's a lot of different factors that go into it and potential challenges. And now I want to start or go on to saying thank you to everybody. I'm going to assume that a number of our organizations that responded may be represented in our audience today. We had 95 organizations represented in our data. That's a lot of questions answered by a lot of people. And within those organizations, based on your result or your answers to the questions, we think it represents about 500 structural heart team members, not including physician operators. So just your coordinators and the rest of your teams that help manage and deliver care to these patients. Our programs were multi-type programs. So we've got large systems and academic programs and tertiary and community care type hospitals and varying types of procedures and volumes. So I'll kind of walk you through that as well. And when we did the math on this, it represents close to 24,000 structural heart procedures in a 12-month period based on what you all reported. So I'm anxious to get in here and show you some of the things that we learned. So just to help level set, this survey really focused on staffing, patient throughput, and some of the roles and responsibility of our team members, both non-procedural and procedural. So I'm going to break this up into non-procedural staff, procedural staff, and then we'll talk about some additional areas related to growth and potential barriers and what you're all experiencing. But I'm going to start with the non-procedural staff. So these are all like your coordinator roles and the people that take care of these patients before and after the procedure that are not necessarily in the procedure rooms. So when we look at the staff roles and employment models, there's a couple of things here I want to direct you to. So number one, our teams are made up of multiple different types of staff members, which actually make me really happy because I did this survey back at about three years ago, and then we weren't seeing quite as much of a mix. And the goal there is as you begin to move a startup program to a program that's much more mature and your volumes grow, we have the ability rather than adding more nurses or adding more APPs, we have the ability to create a bigger diversity in our teams that sort of right-sides our teams based on roles and responsibility and the different people. So you'll see here we've got APPs on the team, RNs, MAs or cardiovascular techs, we've got medical secretaries or patient representatives, abstractors, pre-certification team members, and then we had a few that said other, which you'll find in the full report what those others were. But you can kind of see the most part, the majority of our program all describe multi-different types of or multiple different types of people on their teams. In addition to that, we looked at what percentage of these team members were employed by the hospital or the system versus employed by the private practice physician group. And you'll see that the majority by far are employed by the hospital or by the system. Part of that is because many of our organizations are now represent our integrated models where the physicians are also employed by the same entity. But another part of that is that we've got, and we're going to talk about the clinic type or the clinic location here in a little bit, but the resources oftentimes for these programs are invested by the hospital or the entity which provides the procedures. And that's just usually it's an economic structure that creates that. So the next question had to do with understanding your total structure heart procedure per FTE. And I really like this one when it comes to, we get a lot of questions around, how do I know when to add another staff member? How do I know, our team seems really busy and I need to justify adding more staff to my team. Do you have any data that would help me do that? And that's really what this slide or this graph, I think is going to allow you to do. So what we did is we took the full number of procedures reported by the organizations and then the number of FTE and the FTE is where we normalized it. It didn't matter what type of person RN, PA, CV tech. So if we go back up to this slide, it didn't matter what type of people you had contributing to the care. It had to do with the number of FTE and then dividing that by the number of procedures. And when we normalize the data by looking at it across all roles, this is what we came up with. So the median here is 62 procedures. So the annualized 62 procedures in an annual basis per staff member. So you could kind of start to do the math. If I do 186 procedures, I likely need three FTE of my staff member in order to support that. So 62 per FTE. The 25th percentile was 37. The 75th percentile was 77. And so you can kind of look then and start to do the math on your own program and see where you fall as relates to your staffing per FTE per procedure, or excuse me, procedures per FTE. But I think you'll find that this data can be really helpful in understanding potential productivity or what that looks like. It doesn't tell all the stories. You've got to understand other roles and responsibilities and just some of the different pieces. We'll get into some additional details here in just a minute, but at least it starts to give you some directional feedback as far as where you're at with as an organization when it comes to the number of people related to the number of procedures that you're performing on an annual basis and what that looks like from a productivity or workload perspective. All right. The next section we're going to specifically look at now is structural heart coordinators. So we're looking at only the coordinator role as part of that Fuller team. So think about coordinators. So 98% of you said we have dedicated structural coordinators. So that's the role, that's their title, this is the work that they do, they're focused on structural heart in a care coordinator type role. Then we asked, all right, well, who do you have in that role? 66% said we use an RN in that role, 29% said we use an APP, and 5% noted it's not an RN or an APP, but rather it's an other. And then we asked about the coverage model. So does that coordinator cover more than one type of structural heart procedure or are they focused on just one type? And you'll see that the majority, 82% said no, they cover more than one type versus having a focused role, which again, creates some cross coverage, a little bit of flexibility within the team. What you want to be careful of is this concept of flexibility versus continuity from a patient care perspective, because you know, these patients require a lot of touch points, a lot of care coordination, and the more constant that coordinator role is from a patient perspective, the smoother the flow is going to be and the less likelihood you'll have of any missed call outs or that sort of thing. But I thought it was really interesting that 82% described, nope, they cover more than one type of structural heart procedure. I also thought it was interesting that close to one third of the programs use an APP in this role. I don't think there's a right or wrong answer as far as it's RN versus APP more effective. What I do want to, and I'm going to show you here in just a minute, when we start to break down the type of roles or responsibilities, actually the responsibilities that typically fall within this role, I want you to put your thinking cap on related to, do I really need an APP for that? Do I really need an RN for that? Is that even something I need my coordinator to do? So that actually, we'll talk about that in just a minute. When we look at the breakdown of that coordinator role though, and you can kind of see the types of procedures that we're using a structural heart coordinator for, and then the amount of time they spend with these procedures, you'll see that TAVR and MitraClip or TER, which is catheter edge-to-edge repair, are the two that they had to spend more time on. And that's just, I think, related to the volumes in our programs, as well as the amount of care coordination that these patients require. Not a very far third is left atrial appendage occlusion. So again, part of that is a tricuspid, many of us don't offer that yet. And then some of the others have a little less, I would say, resource requirement because those patients typically aren't as complex or the procedures don't require quite as much care coordination as the others. So now let's get into that coordinator responsibility. So this is another one that when you get to the full report or get the deck, I want you to spend some time thinking about and potentially comparing your team to what we see here. What this is, is it really, it actually, for those that responded to the question, what we asked you was, of all of these responsibilities, which ones of these does your coordinator or is your coordinator responsible for or contribute to? So 58% of the respondents said they function as a program liaison. So they're going out and doing some program development or growth and business development. They're kind of helping to bridge and market us and tell others about us and educate the community on that. 80% said they function and help with the structural heart procedure scheduling. So they're scheduling the TAVR, they're scheduling the TER. 78% said they're scheduling the diagnostic test. So they're scheduling the CT, they're scheduling the TEE, or all those other tests that required both before and after for many of these procedures. 87% said patient engagement education. 88% said patient tracking. 83% described workflow facilitation. And then 61%, you'll see quality assurance, 31% prior auth, 49% denial management. And then you're going to see about a third said data abstraction. And then a very high number, again, 88% said heart team meeting preparation and facilitation of that meeting. But what I want you to notice here is that not as many are doing prior auths, and again, I would agree with that. That's something that can be shuffled at the initial prior auth at least to that, to a different team. Sometimes when you get into the peer-to-peer, so the initial prior auth didn't go through and it gets moved to peer-to-peer, we need to get the licensed individuals that are really close to this work and really close to these patients connected into that. Same way with denial management, if you end up with a denial for reimbursement on the back end, sometimes bringing in some clinical set of eyes. But what I want you to hear is I don't believe that should be a primary responsibility of this team. I think you're spending time doing things, and I'm going to talk about that a little bit more on the next slide, doing things that maybe their license or education don't necessarily require. So when you look to expand your team, making sure we have the right people doing the right work is often really helpful to make sure you're doing it in the most economic and I would say rewarding way for your team members. So this starts to break it into those different responsibilities and the way they spend their time. The way this question was asked is what you did is for each of your coordinator roles, we asked you to break down what percentage of their time they spent on all of these functions. And then we aggregated it up into the data that you see here. So when I go back to, I think we said 58 percent of the coordinators do some program liaison work. They spend an average 7 percent of their time doing that, but they spend 11 percent of their time doing structural heart procedure scheduling, 11 percent of their time doing diagnostic test scheduling, only 13 percent of their time doing patient education and engagement, 13 percent doing patient tracking. And you can kind of see how the rest flow out there. So when you start to really put your kind of program leader hat on, some of these responsibilities, I would argue, probably don't require a registered nurse or an advanced practice provider. So are we using our teams in the most effective way based on the things that we're asking them to do? So when I do some math on this and I circle the areas where I would say you absolutely need a registered nurse to do this work, APP could do this work effectively as well, I would argue that only about 45 percent, and I'm going to add a couple more things in here, 45 percent of the work, the way that it was outlined based on the respondents, really require the license level of the people we have doing this work. And as someone who's had an opportunity to get into a lot of programs across the country, I would say your coordinator role is probably your highest role when it comes to burnout. And I would say one of the reasons that they're struggling with that level of burnout when you ask them, they would say there's a mismatch of responsibilities. I'm asked to do a lot of clerical duties and a lot of other things that don't really use my brain in the way that I was trained, or I feel like I'm doing that work. It has to be done. I'm not suggesting these things don't have to be done, but they're doing that work in exchange of patient-facing work. And so it's doing a couple of things. It's creating an environment where they don't feel that they're utilized in the best way to use their training and their expertise. And two, it's impinging on, you know, their shortcomings. And, you know, they're shortening the time that they want to really spend with patients and make sure that patients have what they need for things like diagnostic test scheduling and procedure scheduling and prior authorization management. So when you start to think about your team, if you're seeing some of those things, kind of go back and talk to them and find out what are the things that they're doing, how are they spending their time, and how can we best balance that out in a way? I'm not suggesting these other activities aren't required. Somebody needs to do them, but how we organized our work across our team in the most effective way, or rather than adding another coordinator role, maybe we need to add a clerical role or an MACB tech role that can help with some of these more task-type oriented type responsibilities. And then the last thing I want to leave you with in this space is this question between APP and registered nurse. And again, I'm not going to tell you that one is maybe better than the other. What I'm going to say is focus on those current responsibilities that you're asking that coordinator role to do and how closely do they match the license level of the person that you have in the role. And this one was surprising for me because when we actually broke the organizations down between those that use APPs and those that use RNs, although you can see that some of the time percentage in the role was less. Actually, that's actually not the way this one was set up. It's actually the percentage of those that use the roles for these things. The reality is it's not that much different. So there are a few that the prior auth and the denial management, the data abstraction is a little less by APPs that are in a coordinator role than nurses that are in a coordinator role as far as those that the percentage that use that role for those functions. But you still see a lot of APPs doing prior authorizations, data abstraction and some of these other pieces. So, again, as you start to think about your team and am I utilizing people in the most effective way based on their training, their skill set, their licensure? I think this is an area you need to look at and that we right sized our team in the most appropriate way. And I'll go back to the challenges. I realize when you are a startup program, your initial role is as a higher licensed role because they can do everything. And so it's important. So then as we grow, are we adding more people like that or are we beginning to create a more variability across our roles and different team members that can start to pull away some of those functions that don't require the higher license level in order to do? So I think those are the key pieces. The other piece I want to mention here is a number of you that are using APPs in the coordinator role. You're also utilizing those APPs to see patients. And we didn't ask the question that way, but I'm confident that you're using them for initial consults or at least tandem visits and follow up visits and things like that. Maybe even some help on the hospital side with HNPs and discharges. But again, as you start to think about how do we grow or utilize our teams better, this might be an area where we start to split the APP role and make that much more of a patient facing role versus the care coordination versus the clerical work, some of the tracking and prior op and those sorts of things. All right, let's talk a little bit about our clinics, though, when we think about our clinics, 76 percent of you reported that you have a centralized structural heart clinic, really that represents a single location for your structural heart care delivery. And 53 percent of the programs describe their patients as getting two bills, which represents hospital outpatient department model. So that was the reason I asked the question around the two bills, because that's the best way to say, is this a hospital outpatient department? They get a facility fee and a professional fee versus if it's being done in an office-based setting. So 53% describe you yourselves as a hospital outpatient department, and that you have a very focused approach around your structural heart care delivery. We then went on to ask about the number of hours per month that your clinic is open, and have staff assigned to it, and then started to look at cross-reference that with the number of procedures that you do. And this allowed us to create some math that suggested, this is all rolled up and there's a lot of aggregated data in here, but it allowed us to kind of land on somewhere around 4.6 clinic hours per procedure, when we looked at the number of procedures per month and the number of hours per month that the clinic was open. The reason I think this is important, again, it's directional, it's not exact, but when you start to look at the investment in your structural heart clinics, and you're looking at expanding to when do I need more clinic time, you can start to kind of compare based on the procedures that you've historically done with the use of the resources related to that clinic. And so if I expand my clinic and I do some math like this, it might help me better understand how much more clinic time do I need to increase my procedure volumes maybe by 20%. And what does that look like? All right, now we're going to switch gears and we're going to move into procedure staffing. So this is thinking about the people that are in the room when we're doing these procedures. So now think about your procedure room and the types of people we have in that space. This is a very busy slide, so I'm going to ask you to print this out, but this is another one that you want to spend some time thinking about and comparing the way your organization is set up. And there were some really interesting findings in that section. And so what I've done or what we've done is we've taken each of these procedures, so you can look at the focal or focused procedure staffing. And under TAVR, you can see 94% of the programs said we have an anesthesia provider in our TAVR. 68% described we have a perfusionist in our TAVR room. 35% said we have a TTE or a TEE physician in our TAVR room. And you can kind of work your way down. 69% said we have RNs that are OR based. 90% said we have RNs that are cath lab based. 57% said we use surgical techs or scrubs that are OR based. 96% said cath rad tech space or that are part of the cath lab space or cath lab staff. 82% said an echocinographer, and 33% described other, which again, when you go to the full report, you'll see what that other was. The reason this is important is because you're going to see there's lots of variability. For some of these roles, if I've only got a third of my programs with a TTE, TEE physician still in the TAVR procedure room, and you're one of those programs, if I was you, I'd be asking why. Why do I, if two-thirds of the programs don't have that person in the room any longer, why do I still have the person in the room? Is there something, you know, something we need to think about or changes in our clinical care, clinical pathway? Again, going back to your clinical leadership, just to ask the questions. We're not in the majority anymore. We're in the minority. Why is that? And do we need to be thinking about something different? And then you can do that same exercise through the TER procedure, the tricuspid clip, the left atrial appendage, and then we added ASD in. So I'll let you kind of read through those, but this is the way to interpret this slide and how to start to think about your own program and where you might fall and where you potentially have some opportunity. Because here's the reality. When we get to the end of this, one of the questions we asked was where are the challenges related to capacity, and it was facility and staff. So now we're starting to talk about staff. If we've got challenges related to our staffing, do we have the right people in the room, and are we managing our staffing in the most effective way with the goal that if we do, maybe we can improve our access? Because that's another, many of you described capacity issues, throughput issues, access issues. We're going to get to that, but I want to bring you back to this section because I do think this section is one of the areas that many of us, many of you do have some opportunities in. And this is the take-home slide. So what we did here is we took each of the procedures and we then averaged the number of staff that were reported to be in the room. So for those of you that answered the survey, we asked you who was in the room, we gave you a drop down, and we let you let us told us who all you had in the room of all these different people and the number of people of each of those roles that you had in the room. For Tavern, the average was 9.5. Many of you might look at that and say, well, that's not surprising. We're right around 9.5. This is what's surprising. Look at the minimum. The minimum was 6. The maximum was 16. So we have a double almost, well, it's two and a half times difference between those at the minimum and the maximum. And I would argue, although maybe in some of our quaternary care centers, tertiary care centers, you're doing, you know, non-traditional access and higher risk patients. Maybe that's the reason why we have the higher numbers. But if I was even at 10, I'd be asking myself, well, how can programs do this effectively with six? So let's go back to those programs and find out what's different about you or different about me. Are our procedures the same? Are our patient populations and acuity levels the same? And is this an area of opportunity? Because when you start to think going from 10 people in a room to six people in a room and reallocating four of those people, that starts to make a big difference in the amount of, you know, of our, the way we use our resources. And you can look across here, TER, we have a minimum of three, a maximum of 12. Tricluspid flip, we have five and 10 left atrial appendage. We have four and nine in ASD. We have, well, we have one, but I'll have to go ahead and just have one. So I'll have to go back to that one. But these others, I think there's definitely, if you look at the range and even think about the standard deviation around that median or average, it's significant. So there's a ton of variability and I'm going to argue that it's not because our patients are different. In some cases, you're going to have higher acuity or high risk programs that do the higher risk patients that require more, but I'm going to say probably not in all the cases. So this was one where we looked at the percentage of respondents and said, these are the types of people that we have have in the room. This is specific to TAVR. And I actually, just to make it a little bit more readable, I did that for each of these. So when you go to print out the report, you'll actually see one for each. So it'll give you a little bit easier visual. I'm not going to walk you or read through all of them, but I've got one for the MitraClip. I've got, or I'm sorry, for TAVR. I've got one for EER, one for tricuspid, and one for left atrial appendage. And you can kind of start to see the differences and then start to compare your program to what is being reported. All right. Well, that was staffing. So now we're just going to transition into some additional considerations and additional questions we asked about your program. So the first one is the national coverage determination waivers. So if you go back to our pandemic, we had a number of nuances or waivers. It's waivers. It's changes that they allowed us to make in our programs to maintain accessibility during a really tough time. So the first question we asked was the percentage of respondents that use the NCD waiver option. And I guess for me to take home here is that it wasn't very many. So 21% of you said we did. And when we did, we used, we transitioned our face-to-face E&M visits to telehealth E&M visits for this patient population. Only 1% changed the way they do anesthesia coverage and 4% did some work related to verbal orders and signature requirement. But again, only one out of five of you that responded to the question described that you had actually done anything different related to those waivers that allowed you. Now that's not necessarily a right or wrong answer. I don't think there's that we all should have or all shouldn't have where I go with this question of the way that what made me think was how quickly or our ability for our programs to transition to something different. So to change process flows or change the way we do things. Do you have a venue in which these decisions can be made? So let's say we've got a change in care patterns or we've got a change. And in this case, our NCD waivers, where does that conversation happen? And where do those decisions get made around our adjustments and workflow? And I still go into a number of organizations, although you're all meeting really well for your heart teams and your shared decision-making. We're not doing as much on the program side where the team is getting together. And we've created an opportunity to start to have those conversations and make those decisions. So, and I saw that's one thing where I think the pandemic really hurt us and not just in the structural heart space, but in a lot of our spaces, we stopped meeting. And part of that was, we all went to Zoom and then after Zoom, no one was showing up. So we just stopped meeting. And in many cases, we've had staffing turnover. We've had other challenges. We're post pandemic. I still say that because I know some of us are, we still had, I mean, it didn't go away, but they were managing it differently. We still haven't really gotten back to that. So I'm going to, it's another thing to think about as far as your programs, do we have a venue or if we want to make some changes or NCD changes have occurred, or we've seen some updates into the way we clinically care for these patients, do you have an ability to get the right people in the room quickly and make those decisions and make those adjustments for your program? The next one was which of the NCD requirements if changed would help alleviate some of your staffing burdens. And as you can see here, two thirds of you said the two operator procedure requirement, a little over half said the face-to-face interventional and cardiothoracic surgery evaluations for the patient, 17% said volume requirements, and then 9% mentioned other. And again, going back to the full report, we'll give you that other. All right, let's transition into structure heart program growth. So we asked you a number of questions related to kind of what were your expectations and, or what do you think are the things that are going to limit your growth? So the first question we asked had to do with your program, oops, sorry about that, capacity limitation, and how much do the following resources limit your program capacity? So to orient you to this slide, look for the lightest green, so it's the top portion of the bar, and those that have the larger light green areas are the areas where we've got the most constraints, or the most that of you reported those constraints, that was the fives. And I would say I circled the ones that I thought had the most, noted the most challenges, and it's your physician availability, your procedural lab availability, and your procedural, from a space perspective, and your procedure lab availability from a staffing perspective. So if you go back to that section on procedural staffing that I showed you, and the degree of variation that we're seeing, I would argue many of us have some work in that space, and it's interesting that it's the same area where we're also seeing the most constraints. So is there, or are there opportunities to start to look at that a little bit different, staff that a little bit different, and actually open up our capacity a little bit more, whether that's better use of our space, better use of our physicians, but I would say most importantly, more access for our patients, and the ability to support the patient, our community need, or the patient need. All right, the next question was percentage growth expected year over year, and every one of you, except maybe one or two of the programs, said that you're expecting program growth. And the areas where we're expecting the most program growth, and in this case you're looking at kind of that lighter blue color, the larger portion of the bar being lighter blue, it's TAVR and left atrial appendage. Some of you are noticing or expecting some growth in the tricuspid area, as well as the TER, but it really is TAVR and left atrial appendage that you're expecting most of that. And you can see that in that, that blue color is the greater than five percent growth year over year. So if you start doing some math on that, that's an extra procedure day, could be an extra procedure day a week, an extra procedure day a month, and then starting to think about what you would need for staffing and resources. And again, I think you can go back up to some of the things that we learned on staffing, those ratios, and start to think of, you know, give you some line of sight around what do I need to do from a resource perspective to prepare for the level of growth that we're expecting. Or maybe we're fostering, right? I think there's a lot of our communities, in fact, I don't have the data here, but I've seen the data that suggests that we're under penetrated as far as the care for these patients. And so how do we right size ourselves to better meet that need? So that segues great into this question that had to do with what are those strategies that organizations are really leaning on to support program growth. So 83 percent said we're going to, we're actually deliberately increasing our procedure volumes. We're going to plan to do more procedures, we're adding more time, we're going to add the right resources to match that. 82 percent said we're going to do more outreach and marketing. 53 percent said we're going to do echo mining, and I'm going to show you some additional details on that in a minute. Almost half said we're going to be adding more providers, and then you can see infrastructure investments, imaging investments, and then adding additional procedure types. So many of you might be moving into the tricuspid space, or if you haven't already, into the TER space and starting to think about that. All right, so how do we identify our patients? So starting to think about growth or just patient capture. I still argue we talk about growth, but the reality is these patients live in our system already. They're here, but with us, and we just have to find them. So how are we going about that? So 60 percent of the program respondents said that they mine their clinical data to identify structural heart patients, and then we asked what type of data are you mining? Of those, 100 percent of them that do mine said we do echo mining, so we echo findings, and 36 percent, about a third, said we also mine our EMR data. And then my question was, well, how do you turn that data into action? So 76 percent said when I identify the patient through the mining activity or exercise, I send a request to the referring physician to place the consult. So if a physician ordered an echo, and I identify that patient as having severe aortic stenosis, they're going to send a note to that ordering physician and say we think your patient qualifies. We'd like to see them in our program. 15 percent go ahead and put in a consult facilitated by the staff. So in essence, they have a standing order. When patients meet certain criteria, we're going to automatically refer them and offer that patient a visit with our structural heart team. So I think, you know, the question is reactive versus active when we identify the patient and where does that decision making occur. And I just think for those of you that are still up that part of that 76 percent, although it's a great initiative and you're identifying and you're, you know, creating clinical decision support for that ordering physician, I want you to see that it's not out of the question to transition into more of an automatic type of referral that the patient meets criteria. And we as an organization or as a clinical leadership have decided that every patient that meets certain criteria deserves an evaluation. And we're going to let the patient decide. And it's not that you're going to take the ordering physician out of it. It's a collaborative. But the goal is to create an environment where we have the least amount of friction as possible and the least amount of decision points where things can fall through the cracks. So it's less likely that that physician won't make the appropriate decision. It's more likely did he or she see the note that we sent over or was it sent over in a way that they can take easy action on it and allow that activity to occur or allow that referral to happen. I think it's just a matter of thinking about the way your program is set up and seeing that, oh, there may be some other opportunities or ways we could start to automate some of these things and create less friction within our referral pathways. All right. We're almost done. And then we'll open it up for some questions. The last couple sections, the first one had to do with some program economics and just really understanding where you're at and what things are being measured. I think that was the biggest question is who's calculating what. So 63 percent said you're calculating upstream revenue. Upstream revenue in this case is defined as the revenue generated for the patient activities prior, patient rendered services prior to the procedure. So the ECHOs, the CT scans, in some cases the TEEs, all of those services, what's that upstream revenue for this that then potentially supports this program? Sixty-three percent of you said we can we can track that. Sixty-nine percent said we track downstream revenue. So that's the revenue after the procedure. So those follow-up imaging studies and follow-up visits that happen in that, you know, six to twelve months after these procedures. Thirty-one percent said that you track patient acquisition. So what's the percentage of patients that go from referral to actually being seen in our clinic? And 27 percent track patient retention. What percentage of those patients were referral that went on to receive, that were qualified for a procedure, that went on to receive a procedure? And then for other, you can see that there were a number of things in there related to financial loss and something related to kind of the way they track things through their registry. But most programs calculate downstream, upstream and downstream. The next one had to do with margin performance. So again, our goal is not to ask you specific numbers, but really give us a more of a quantitative direction as far as where these procedures fall within your perspective when it comes to margin. And so how do these procedures affect your margin was the question. And most programs declared that TAVR, TER and left atrial appendage as either small positive margin, while most programs were unsure of the margin related to tricuspid. And that might be just because we haven't been doing them as long. And many of the, you know, not as many programs at this point are doing them. So, but you can kind of see how these are broke down. We did based on large positive, small positive, break even, small negative, large negative. And you'll see for the dark blue, which is TAVR, I'll just call that one out. The rest of them, you can kind of look at on your own, but you'll see the majority of programs by far describe a large or a small positive. So if you're one of these programs is still looking at break even, or think it's small negative or large negative, does an area go back and look again? Are your patients that much different? Is, and I get reimbursement, there's a range, and I understand certain parts of the country, but I think it's worth, if you haven't looked at it in a while, going back and understanding really where you do fall. And if you do fall different than the majority of the respondents, probably time for a deep dive to really ask why and what are we seeing? All right, so let's talk about referral pattern or referral tracking. So only 30% of the respondents reported tracking the referral to procedure range. And if I was an administrator, I would wanna know this. If I was a clinical team member, I would wanna know this because it creates an environment where I understand what my yield is. It also helps me understand am I getting appropriate referrals? If my referral to procedure is on the higher side, it would suggest that the majority of the patients that are being referred to me really do qualify for the procedure. If it's low, what's my problem? Is my problem that the patients I'm being referred to are not the appropriate patients? Then I need to go back and educate my referring physicians or my wherever these patients are coming from. Or is it low because my wait times are so long that although we might be initially seeing the patients, they end up going someplace else because they can't get into our program. So I think this is an area where it's really important for you at least to be tracking. And then for those that are tracking, so the 30% that are, we ask the question, what's your average percentage that goes from a referral and turned into a procedure? So for TAVR, it was 70%. For TER, it was 56%, right? For PICUSPIT, it was 43%. And for left atrial appendage, it was 68%. If you're looking for a benchmark, and I get that this is self-reported data, but it's probably the best we have at this point, this would be a good place to start where you compare as to what the average percentage that we saw within our respondents. The next one had to do with time of referral request to initial consult. So there's two time measurements we asked about here. The first one is when the referral comes in, how long does it take before we can get them in for that actual consult? So you can see less than 10% of our respondents said less than seven days. The majority said seven to 14 days, but we still have quite a few that are at 15 to 28 days. That's just to get them in for the consult, let alone get them in for their actual referral request to procedure. So if we go to the next slide, 63% do track referral, initial referral to intervention procedure. And you can see here we've got the majority of you actually fall greater than 28 days. So I'm not surprised just because of the work that we've done and the exposure that we have with this. This is not a new number for us. And I do think that many of our organizations, many of you are challenged with staffing and challenged with facility time. I mean, you're telling us this, so there's reason for it, but this is where we need to start looking at, how are we doing things? What did we learn from some of those earlier questions? And what opportunities do we have with the ability to get these patients in sooner? Remember, these are not like your typical chronic disease management patients where you're gonna have them for years. In fact, in severe aortic stenosis, we know that their mortality, by the time they show up in your doorstep, they're symptomatic. And depending on which symptoms they're having, their mortality window is very low, meaning that the longer it takes for them to get into your program, the less likely they are to move through for a successful procedure. And so, and you've all seen that data. And so I think it's imperative that as we think about the way our programs are set up, how do we capture these, not only capture these patients appropriately, but once they're captured, how do we create an environment that we can get them in and get them treated so that they can go on to live a better life post-procedure? All right, so some key takeaways. And then I think we've got maybe 10 minutes for some questions. So number one, structure how staffing is still widely variable, including staff ratios, staff type, roles and responsibilities, suggesting the need to streamline and create best practices. I did this survey, I think I mentioned about three years ago, and I was really hoping that we would see kind of an improvement in the variability around the responses to the questions. And I think we did related to the number and the types of people that we have involved in our program teams. But I don't think we made a lot of movement in some of the other areas. There's still a lot of variation. And I'm gonna go back to, this is one of those patient populations and procedures is pretty finite. In other words, what needs to happen is the same for program to program, the types of patients that we're taking care of and the comorbidities for the most part are the same program to program. So why do we have so much variability in this and what can we learn from each other as far as shoring some of that up? All right, number two, structural heart coordinator is a common role with the majority of organizations using an RN for this and the majority of the responsibilities falling within the RN school practice, but not all the responsibilities. So I mentioned that already, there's a number of clerical pieces in there and then a number of these coordinator roles that are actually an APP. Again, I'm not gonna tell you the APP is the wrong person for the role, but have you shifted that role into much more of a patient facing E&M provider type role along with some care coordination or are we still sitting with majority of it being care coordination and clerical work like tracking and data abstraction and things like that. So really go back to that role and find out what are their daily responsibilities and the things that they're involved in and how can we better align that to their training and to their license. All right, number three, procedure staffing type and the number present are incredibly variable, suggesting that most organizations have an opportunity to streamline and redeploy staff other functions. When I get into the walls of the hospital and get into the walls of the procedure areas, we know we're in a staffing crisis. I think I've been in a cath lab in months that isn't short in some ways. I'm not seeing quite as many travelers as I was, but at the end of the day, we're still dealing with less people than we have work to do and asking people to do a lot. So is this an area where we can look at, we've been doing this procedure for a number of years now for many of you and we haven't really adjusted how we staff these rooms. Is there an opportunity to start to pull some staff back and redeploy them in other areas or if we've got space, do we have the ability to create a couple of teams or get creative with the way we use our team that might increase throughput throughout the day and move us from a four procedure day to a six procedure day or something along that line. And then the final one is structure heart growth is anticipated by 98% of youth. I'll go beyond most, it's pretty much all. However, you're all noting staff constraints and half of facility constraints. So I mean, it's kind of the same question. When's the last time you went back and reviewed your staffing models and your facility use? Where do you fall in comparison to what we saw earlier in the report as far as how you're using your staffing and the different people that you have on your team? So as structural heart capacity needs increase has your organization adopted more contemporary models of care? And there's a lot there. I didn't go into what those newer models look like today. We definitely can address them in future and we've got different webinars and things in the past. And there's just, there's a lot of literature out there on different newer clinical pathways for these patient population. This was more of just to kind of give you all some benchmarking data or help you understand where you might fall or where there might be opportunities. But I think that's the question that I'm gonna leave you with as far as thinking about your program. With that, I'm actually gonna, Katie Willerick is on with me who, Katie helped me with a lot of the data analysis for this. So thank you, Katie, for all of that work. And then let's see what questions, if we had any questions. Yeah, Ginger, we have a handful of questions and I apologize, I'm gonna stay off camera. My internet is wonky right now. First question is what percent of programs are using their anesthesia physician as their TEE physician? I wish I had that number. I don't have it right now. I know that it's happening, but that's probably the best that I can give you to say it. I know it's not unique, but I don't, we did not ask that question as part of the survey, so I don't know. Right, the next is just a comment, which I just wanted to read out there in case everybody can't see it. This comes from Diane. I think it is important to correlate the program's outcomes with the number of people in the room. You are assuming everyone's outcomes are the same. That's a very fair comment, and we did not get into kind of correlating quality. I would say though that, I'm trying to think of how you can do that internally and start to think about, because I'm not sure that there's gonna be any specific data source that is going to do that for you at an aggregated level, because it's kind of two different sets of data and the way they're compared. But that being said, I think it's important. I think it's fair. I think it's fair to go back and look at just how we have our program set up, the roles and responsibilities of all the different individuals that touch these patients and where there might be some non-value add type work or some maybe in more cases redundancy. Redundancy that where we pull back from the redundancy is not meant to pull back from the quality of the work that's happening or the quality of our outcomes, but rather do we have things shored up in a way that we not only are we high quality, but we're assuring that we're cost effective. And I think the reason to do this work, although I incredibly respect what you're saying, is that we also have, most of us have access. And so although we're providing great quality of care for the patients that are making it into our program and getting to the procedure, what are the number of patients that didn't make it in? Or what are the... And again, I'm not suggesting we lower quality to increase throughput. That is not at all what I am suggesting. But what I am saying is sometimes we assume that the way we're set up and the way we're using our teams is the best way because our quality is high, but you may get just as high quality with a transition or a little bit of an adjustment that can also improve some of your throughput or improve some of your access. So I think that's, again, if you can take it back to the quadruple aim, we don't wanna lose track of the quadruple aim either. Part of this is team wellbeing, as much as it is patient wellbeing and patient outcomes, as much as it is quality outcomes and the cost effectiveness piece of it. But in this case, the cost effectiveness piece means can I see a few more patients? Not asking people to work harder, but maybe work a little bit differently that will improve the care that I'm providing to my community. So I know that doesn't really answer your question. I get what you're saying, and I think that's an important perspective that you need to take when you look at your data and you look at where you're staffing and some of your other things fall compared to what we saw on here. And maybe you start with what's the median? If I think about TAVR, the median is nine and a half people. How many people do I have in my room? If I have 12, do I need 12? Those are the sorts of questions you can start to ask it. Thanks, Ginger. The next was in regards to the NCD. Is the NCD applicable to all structural heart procedures or just TAVR? And is this for the procedure monitoring too? For example, couldn't anesthesiologists do the pre-procedure assessment, but a CRNA perform the case? So I don't have that level of information at the tip of my tongue to answer the question. I can't answer because you had two questions in there. The NCDs are specific to the procedure. So TAVR has an NCD, TER has an NCD, left atrial appendage has an NCD. And so within those NCDs are national coverage determination documents. Are the rules you all have to live by when it comes to performing the procedure so that you can get reimbursed for the procedure? I cannot answer the question related to the anesthesia and the AP, or I'm sorry, the nurse anesthetist. That being said, I could get that answer for you. So, and for those questions that we don't get to today, because I know we're only down to a couple of minutes now, we'll look at those and get those answers back to you. We can tell who asked those. And if they're a common question, sometimes, and I'll look, I can't see them from my screen view right now, that sometimes we'll even do a FAQ type document and get that back out to everybody that attended. So we'll get that information to you. Perfect. Next question. Did you collect any data on those programs that do moderate sedation for TAVRs? Is the staffing criteria would be different? Interested as we are in beginning stages of transitioning. That may very well be one of the levers as to why we see programs with lower staffing requirements, or I'm gonna say requirements, but staffing use is what this looked for. We did not get into the clinical care patterns with this survey. So I don't have a way of saying, okay, well, those that use six to eight people use moderate sedation or nurse-led sedation versus MAC versus general. That may very well be one of the levers that they used. All right. We had a couple of questions on the location of procedures. Did we collect data on whether it was an OR versus the cath lab versus hybrid? I love that question and we did not. So what I'm hearing though is with a number of these clinical questions, it may be worth going back and doing some additional, not going back, going forward, and thinking about a follow-up survey that focuses a little bit more on the clinical care and focuses a little bit more on the clinical pieces and just understanding practice patterns. So we'll kind of internally review that, but I appreciate the question, but we did not get into the clinical patterns for patient care with this. There are a number of questions on the slides regarding the number of procedures per FTE, Ginger. I don't know if we wanna go back over that or just refer everybody to the report and I could possibly answer some of the questions. The gist is that most people just wanna understand if they're interpreting it correctly and also if that includes providers, MDs and APPs and the FTEs. So it does not include physicians, but it would include APPs if the organizations reported APPs as contributing to the care for these structural heart patients. So the methods behind that question was we asked everybody to report through annual volumes of the different types of structural heart procedures that they perform. Then we asked them to give us the FTE counts of the different staff members that they had that contributed to the care. With the ideas, I might have a 1.0 RN, but if he or she is only dedicated to the structural heart program or to the TAVR program or the left atrial appendage program, a 0.5, then I'm only gonna count 0.5. That's kind of how we asked the question. We rolled it up. So again, when we asked the staffing, we asked how many APPs, how many RNs, how many MAs, CV techs, how many of all of your people? And let's say program one said we've got 10.5 people that are allocated to our structural heart program. That same program said, and we do 75 TAVR, we do 150 TERs, we do 150 left atrial appendage, and those are wonky numbers. So I'm just making it up. But they came at the bottom and they said, we did 250 programs last year, or I'm sorry, procedures last year across all of our structural heart procedures. And we had 10.5 staff allocated to delivering care. This also did not include procedural staff. This was just on the non-procedural mix. So don't think about all those people in the room for the procedure. I'm talking about coordinators, clerical team members, abstractors, all of those people. If they did 250 procedures and they had 10 people, 10 FTE, so they could have had more than 10 people, but if the FTE added up to 10, we divided 250 by 10, and that would have created 25 procedures per FTE. So it's a roll-up of all structural heart type procedures. I completely get some of those procedures require more resources than others, and it's a roll-up of all the staffing that was described as being allocated. And I get that too, that you can have more RNs, and some people have all RNs, some people have MAs, some people have a bigger mix. Nobody has all MAs, but has a mix of people. The concept is this, we did it this way to normalize. I would argue, although the structural heart procedures themselves may have different requirements of what needs to happen from a care coordination perspective, the work of the staff, it's all the same work. It's just how we organize it. Some of us use all nurses, some of us use a mix. So that's why I rolled, I didn't look at it per roll type, I looked at it per the full allocation. So it's a total number of FTE, total number of procedures, and then we aggregated it across, and that's where then you got your 75th, 50th, and 25th percentile. And I think that gets us, actually took us over a minute, took me a little bit to hopefully answer that question. So I'm just gonna wrap it up here. I appreciate for all of you that contributed, thank you. This is, it's because of your willingness to fill out these surveys, that we can get this sort of information back in your hands. And I hope that there was something in here that you found useful. Take some of these key takeaways, think about your programs. We definitely have, I always like when I read a good report at the bottom saying, and we need to look at these other things, or future research should include, and I would say future research should include, how does this, you know, we wanna make sure we've got good quality, and how did the, is there any association? How, what did our care patterns look like, and what's our use of anesthesia? And so, yes, future research will definitely look at those things. So thank you for joining today. The full reports on our website, you'll see a little more come out. This will be recorded. If there's anybody else that would like to see it, we'll get you the link, and we'll go through the questions, and anything we didn't get to answer today, we'll get some information back out to you. So have a good rest of your Monday, have a great week, and thanks for joining today.

structural heart program opportunities

staffing trends

care coordination

resource allocation

survey

staffing challenges

growth opportunities

staffing roles

structural heart coordinators

NCD waivers