These partnerships included community-based emergency services, nursing homes, rehabilitation partners and hospice providers.

Initially, Buonocore’s work focused on heart failure patients, then expanded to incorporate major cardiac procedures included in the Centers for Medicare & Medicaid Services (CMS) Cardiac Care Episode Payment Model (EPM): acute myocardial infarction (AMI), acute myocardial infarction percutaneous coronary intervention (AMI-PCI), coronary artery bypass grafting (CABG). She was invited to the Cardiovascular Service Line Rapid Design Session to share her successful process and learnings.

“There are some very specific criteria which are critical to the success of building a partner-based continuum of care for our cardiac patients,” said Buonocore. “Those include each entity’s understanding of expectations for excellent patient care and leadership’s support on data-based performance process, procedures and benchmarks. This must necessarily be patient care- and family-focused."

“Regular communication among the interdisciplinary cardiac teams, the nurses who help navigate our cardiac patients and their families through the continuum of care where our partners in the community provide service is essential,” said Buonocore. “But equally important is the ongoing education process we provide our patients, their families and our cardiac care providers. That education process is critical to successful care prior to major cardiac procedures, and postoperatively as patients move from the hospital setting into extended care.”

Buonocore emphasized that it is important to celebrate successes by sharing best practices and successful patient outcomes with other clinicians and providers. “There is likely nothing more motivating to those of us in cardiac care than hearing how better patient outcomes came out of some shared learning or data,” she said. “Ultimately, we do this to provide the best care for our heart patients and their families.”