Transcatheter Aortic Valve Replacement and Collaboration at Intermountain Heart Center

Dr. Whisenant, you have been involved in TAVR since the early PARTNER days. Can you describe the structure of your program in the beginning and how it developed?

Brian Whisenant, MD: We initially attempted to integrate the TAVR program into our existing clinical structure. It soon became apparent that the TAVR program demanded greater focus and resources than the existing model could provide. Today, we have a structural heart team with several physicians, advanced practice clinicians, medical assistants, and research coordinators. We keep lists of patients referred for TAVR and other structural heart procedures and review our plan for each patient at least weekly. I credit both Intermountain Medical Center leaders as well as the numerous collaborating physicians for recognizing the value of structural heart disease and dedicating tremendous time, energy, and resources to building a program focused on quality patient care.

In those early days, what goals did you set for your program and how did you go about achieving them?

Brian Whisenant, MD: Our earliest goals were to provide quality clinical care and quality service to both our patients and our referring physicians. Collaboration was and remains absolutely essential to our procedural outcomes. Cardiothoracic surgery, vascular surgery, critical care, radiology, and cardiac anesthesia are each committed to our TAVR program and provide essential aspects of each patient’s care.

Our advanced practice clinicians, medical assistants, and research coordinators demonstrate genuine care and concern for our patients. With the initial referral, they become acquainted with the patient and the patient’s family. Patients are provided with a contact person and telephone number who will help them navigate testing, travel and accommodations. Patients are greeted on arrival by a medical assistant and escorted to various tests.

What is your vision for the future of your program?

Brian Whisenant, MD: The shared vision of the Intermountain Heart Institute at Intermountain Medical Center is to provide advanced, responsive, and coordinated care to each unique patient, and to be recognized for our expertise with even the most complex heart problems. I hope the structural heart program will be increasingly appreciated by our community of patients and physicians for meeting these standards.

Ms. Snyder, new centers often request a job description for a TAVR coordinator. How would you describe your role and the qualities of an ideal TAVR coordinator?

Mandy Snyder, NP, TAVR Coordinator: We have separated the functions that may be included in the typical description of a TAVR coordinator. Our patient access coordinator and medical assistant schedule physician visits, diagnostic studies and structural heart procedures. This involves establishing patient relationships and coordination with radiology, the pulmonary lab and the cath lab. They initiate insurance preauthorization, which can be challenging, as many patients are referred from out-of-state and out of network.

My role has an emphasis on clinical care and patient education. I am involved in all aspects of our patients’ medical care, with exception of the valve implantation. Upon initial consultation, I provide education about the pathophysiology and treatment options. I arrange for hospital admissions with instructions pre-procedure. I assist with the history and physical, admitting orders, post procedure ICU orders, transfer orders, daily rounding, discharge orders and post procedure follow-up.
Our patients have many questions and concerns regarding their disease and treatment options. Anticipating our patients’ needs and questions helps them transition through the care continuum. Helping our patients feel comfortable without becoming overwhelmed is an emphasis of not only our “TAVR coordinators”, but our entire team. Our patients need to know where they are going, when to arrive, how to register, and who they will meet. They often want to know about the success rates of our team, how many procedures we have performed, how long they will be in the hospital, how long their recovery is expected to be, and if their insurance will cover the procedure.
High levels of organization and being “available” are essential qualities in a TAVR coordinator. We strive to provide patients with clear directions over the telephone, in electronic mail and print, thereby alleviating uncertainty and hopefully establishing confidence in our role as providers.

What advice do you have for new TAVR coordinators?

Mandy Snyder, NP: New TAVR coordinators need to be organized, follow through with commitments, and approach the position from a mindset of the patient. This population is frail and elderly with limited mobility. They often struggle with basic needs and require additional time and support with items such as transportation, getting from their car to the clinic, or walking from one department to the next. They may need assistance disrobing for diagnostic procedures. Having someone who can help them with this goes a long way. Providing prompt feedback to patients and referring providers is also essential. The constant flow of communication is such a necessary part of what we do. Attending conferences and networking with other centers can be helpful in working out the wrinkles that occur in the system.

Who makes up the rest of your valve clinic team, and what are the roles and responsibilities of each team member?

Mandy Snyder, NP: We have a structural heart disease (SHD) access coordinator who functions as a liaison and is often involved in early communications with our patients and the referring providers. 

A medical assistant assists our team with scheduling and with normal operation of our clinic.
 A physician assistant on our team functions in a role similar to my own. We have two study coordinators who assist with following the patients enrolled in the Edwards PARTNER Trial and other structural heart trials. Two administrative assistants work in the surgeons’ offices and assist with coordination and consultation scheduling. We also have an individual who assists with billing and coding for our TAVR procedures.

How are potential TAVR patients identified?

Mandy Snyder, NP: A majority of our new TAVR patients are direct referrals from providers within our practice and outside facilities. An important aspect of building and maintaining a relationship with the referral network has been timely communication with their offices. We provide feedback following screening, post valve implantation, and at follow up post hospitalization.

Can you describe your process for screening and evaluating patients?

Mandy Snyder, NP: Prior to beginning the screening process, we coordinate with referring providers to have access to images and reports for the patients’ most recent echocardiograms and cardiac catheterization. We determine what studies are necessary and arrange for cardiothoracic surgery consultation.

Our screening process involves an initial consultation with a detailed discussion of treatment options. We coordinate between outpatient testing and admission in our cardiac procedures unit to complete all necessary screening. After evaluation of initial screening data and discussion of appropriate treatment with our structural heart team, we offer treatment options to the patients and their family members.

How are patients tracked through the process?

Mandy Snyder, NP: We maintain a database with relevant patient information, including the referring provider’s name, contact numbers of the patient and their family, and any significant other information. We track all of our patients with notes on their status and upcoming events. We review active patient information on a weekly basis at a minimum and update our information following consultation, screening, and procedures.

How have you been educating your referring community about TAVR as an option to treat patients with severe, symptomatic calcified aortic valve stenosis?

Brian Whisenant, MD: One of the rewarding aspects of our TAVR program has been the opportunity to become better acquainted with the cardiology community of the Intermountain West. Dr. Kent Jones of cardiothoracic surgery and I have given grand rounds in numerous hospitals around the region. I am able to better serve my patients when I have an open line of communication with the referring doctor, and he or she is comfortable dialing my cell phone.

Reflecting back on the evolution of your program, what are you most proud of?

Brian Whisenant, MD: I am most proud of working in a hospital and with a team of physicians and care givers who are committed to providing outstanding care. There is great satisfaction in the service we provide our patients.