UNC Health Talk

Transitioning Heart Patients Back to Primary Care

As a primary care physician, you know the challenges of managing a large population of patients who are at risk of heart disease. You often rely on cardiologists to get their hearts healthy, but then you are tasked with keeping them healthy once they come back to you. So how do cardiologists determine when to transition patients back to your care?

James Jollis, MD, a cardiologist with North Carolina Heart & Vascular, discusses the collaborative relationship between cardiologists and primary care providers and what tools he and his team use to keep you informed.

While patients are under your care, how do you keep primary care providers in the loop about their progress?

We use the Epic electronic health records system. Epic records are shared with primary care providers so they get our discharge summaries for patients we see in the hospital, as well as our patient encounter summaries for those we see in outpatient settings. The summaries include test results, changes in medications, follow-up appointments, and discharge or follow-up instructions. Any referring physician who uses Epic has access to this information in the Epic system. Those reports should be sent by fax or mail to physicians who are not on Epic.

What is the collaboration like between you and a primary care provider after a patient leaves your care?

Our level of involvement depends on primary care providers and what they are comfortable handling versus where they want us to help. Most manage their patients’ ongoing care and reach out to us in consult if a problem arises.

In general, we look to primary care providers to monitor things such as:

  • Medication side effects and issues, such as bleeding and anemia, renal function and electrolytes, and medication compliance. For some conditions and patients, medications can be challenging to take because of cost issues or other reasons. For certain conditions such as recent coronary artery stent, mechanical heart valve or atrial fibrillation with higher risk for stroke, failing to take medications can result in catastrophic outcomes such as stroke, heart attack or death. Often, compliance can be achieved by stressing the importance of these specific medications and offering alternatives or financial assistance for those who cannot afford prescribed treatments.
  • Blood pressure issues. More than half of people age 60 and older have high blood pressure, and most require two to three medications for blood pressure control, which can cause side effects. Blood pressure medication is something we often work back and forth on with primary care providers.

For cardiologists, our level of involvement varies based on the diagnosis:

Coronary Symptoms

After we have treated patients with acute coronary symptoms, where there is some sort of block, we are happy to have primary care providers involved in the follow-up care to whatever degree they are comfortable. If they want to order necessary follow-up tests, they can. But we are here for whatever level of support they need—whether it’s reading an EKG, talking to the patient’s family or representative, or reviewing test results. If there are complications after a procedure, the primary care provider should send the patient back to the facility where the treatment was performed.

Atrial Fibrillation

For atrial fibrillation patients, we work with primary care providers to make sure they understand the treatment we performed, the medications the patient needs and when they might need to contact us moving forward. Primary care providers are tasked with helping patients comply with medications and monitoring them for bleeding complications.

Heart Failure

For patients with heart failure, there are a lot of resources in place to ease the transition from the hospital to home. We give patients medications in the hospital and ensure they are fully equipped to follow instructions after discharge. We rely on primary care providers to monitor patients for complications and compliance with medications. We are available to help if complications arise.

How does a primary care provider know that a patient needs to go back to the cardiologist? What red flags should they look for?

Two of the main reasons patients come back to us are due to a closed artery or atrial fibrillation. Most primary care providers perform EKGs to determine the possibility of a closed artery. For atrial fibrillation, we rely on the primary care provider to identify the source of what’s causing it and evaluate symptoms and stroke risk. If a physician picks up on hyperthyroidism or pneumonia, those can cause A-fib. Other red flags include dizziness and severely high blood pressure.

What is your relationship with primary care providers once a patient is transferred back to their care?

Primary care providers have long-term relationships with their patients and are an integral part of their ongoing cardiac care. If they have any questions or if the patient is getting worse, they can refer back to us. Primary care providers and cardiologists tend to have great relationships with each other. We all have Epic message, but there’s no substitute for talking. We frequently consult with primary care providers by phone.

What tools, tips or advice do you give patients to help with their ongoing care?

We review medications and how to take them before they leave our care. We also put a plan in place in case they have problems, including making sure they know when to call 911 or notify their cardiologist and their primary care provider. We talk through weight goals and symptoms and what to do with diuretics. It really takes a team effort with the patient, the primary care provider and the cardiologist to ensure the best possible outcome for the patient.

Learn more about North Carolina Heart & Vascular and how to make a referral.