Melanie Cole, MS (Host): Welcome to the podcast series from the Specialists at Penn Medicine. I'm Melanie Cole, and today we're talking about the important work provided by Advanced Practice Providers at the Surveillance Clinic at Penn Medicine. Joining me is Melanie Freas. She's a Nurse Practitioner and the Clinical Program Manager at the Center for Bicuspid Aortic Valve Diseases at Penn Medicine.

Melanie, thank you so much for being with us today. Can you start by telling other providers what is a surveillance clinic? What is that?

Melanie Freas, DNP, CRNP: Oh, absolutely. So thank you for having me on your program to talk about this. It's very special in my heart. So when we're talking about surveillance, we're really talking about following a patient's progression through looking at test results and adjusting their treatment plans.

And we do this by follow-up appointments, reviewing test results such as echocardiograms, CAT scans, and MRIs.

Host: So, when and how did it get started at Penn Cardiac Thoracic Surgery? When did this get started?

Melanie Freas, DNP, CRNP: So this got started actually in the year 2004. Our cardiac surgery program was really starting to take off, and we noticed that a lot of our patients didn't need surgery immediately, but needed to be closely followed. So we were having them come back in six-month intervals, one-month intervals.

Well, this was preventing new patients from getting in and kind of limiting the spaces we had available. So we needed to come up with an option where we could still follow these patients very closely, still had direct connections with our surgeons, and were able to expedite any appointments when they were ready for surgery.

Another issue we had was wait times. And by putting this surveillance clinic together, we were able to decrease our wait times.

Some of our patients were waiting two or three hours to see the surgeon. And that's just not optimal. So we were able to decrease our wait time in our surveillance clinics to five to 10 minutes before you got to see a provider. We also found that these surveillance clinics were going to provide a more relaxed atmosphere for individualized attention and education for our patients and their family.

In 2018 and 2019, we conducted some research on patient satisfaction and presented these at conferences both nationally and internationally. And they were demonstrating the success of an advanced practice-led clinic. Our surgical clinics had an 82% return rate for surveillance patients, and they did this with follow-up letters, and phone calls and helping them set up appropriate testing.

When these patients started to attend our nurse practitioner run clinics, we found that their return rate increased to 98%, and this was because the appointments were scheduled at the end of the visits and orders for the upcoming testing was given to the patient, and explanations were given as well.

We also saw when we reevaluated these patients in our surveillance clinics, they were giving us five star ratings. They loved that individual attention. I have to tell you that we didn't really expect the impact these surveillance clinics would have. Advanced practice clinics are now a standard, and not just for specialties, like cardiac surgery, but in primary care and dermatology.

I've served as a consultant for several organizations throughout the United Healthcare Hospitals, and we've hosted some of their nurses to show them our program, to walk them through how does our surveillance clinic work? How do you start it up? And we're also hosting people from Europe and the UK who are interested in our programs.

Host: That's so interesting. Thank you for sharing that with us. How many surveillance clinics are at PENN and who leads them?

Melanie Freas, DNP, CRNP: Well, right now we have three. We have a general thoracic surveillance clinic that's just general aortic aneurysms, and that's run by Kate Rosemann, who is our lead Nurse Practitioner.

The Bicuspid Aortic Valve Center, we started that in 2019, and that was developed and is currently run by me. And then the newest of our surveillance clinics is our dissection clinic for patients who've had dissections, aortic dissections, and that is also run by Kate Rosemann.

Host: Tell us about the patients that are admitted into the program for surveillance. Tell us a little bit about patient selection.

Melanie Freas, DNP, CRNP: Patient selection is very important. You have to be deemed stable by your surgeon. So 90% of our patients are going to come in, they're going to see a surgeon. Surgeon's going to review all their testing with them, and then they'll determine whether or not they need surgery. If they need close observation, then they're going to be placed in our surveillance clinic. And all of these expectations are laid out right from the beginning with our patients, that you're going to see the surgeon to a certain point, and then there won't be a need for the surgeon. But there's a strong need for you to stay connected with us, and that's more appropriate for our postoperative patients.

Aortic disease can be very complicated and patients will sometimes require more than just one surgery. And our surveillance clinic allows us to keep them in the system, keep a close eye on them before they go for any additional surgeries. It's important to say that we're not replacing the care of these other providers such as primary care or cardiology.

Our patients are still followed by their primary cardiologist. This is very important because it coordinates care with other providers to ensure that we're all on the same plan and that we're all dealing with the same treatment ideas and that the expectations are there. We're just here to give them an expert surgical opinion.

Host: What important work you do, Melanie. So, how many patients can you handle at the surveillance clinic? How many patients are seen and placed in surveillance?

Melanie Freas, DNP, CRNP: We have a lot of patients that we see in surveillance. Between our three clinics, we see a total of 1400 patients a year. I can break this down. Using the example of the bicuspid clinic, since I'm the primary provider in that clinic, we have over 2000 patients registered in our clinic, and I will see these patients at one to two year intervals.

Over the past six years, we've added probably about 60 to 70 new patients to our surveillance clinic, to follow before they need surgery. And it just keeps growing.

Host: What a great program. . Now, tell us a little bit more about its role at the Aorta Center and how you work together.

Melanie Freas, DNP, CRNP: . So we're under the clinical arm of that program. And we strive for this comprehensive treatment and follow-up for all our patients.

Monitoring for patients with aortic disease is crucial. These conditions are variable. They can change, whether they require surgery or don't need a surgical intervention, they still need to be followed. We expanded our efforts to ensure that every patient received consistent and beneficial follow-up care in our surveillances.

And we've put a lot of time into the infrastructure to keep track of all these patients. We like to say that we're not using the disease-focused model anymore. We're using a patient-centered focus, so there's a lot of time to understand these patients and their lifestyles.

Host: Melanie, how long have you had some patients in the surveillance clinic?

Melanie Freas, DNP, CRNP: If you go back, there have been patients in my clinic that actually started their care here in 1996 and have been very consistent with their follow up every year. I think the majority of our patients have been following for about 10 to 15 years, which is phenomenal to be able to see a patient over that long period of time.

Host: This is really great information you've shared with us today. As we wrap up, where do referrals come from? How can someone refer to you at the surveillance clinic? Tell us a little bit about the process.

Melanie Freas, DNP, CRNP: Sure, that's very important. So, any referring primary care doctor or cardiologist can go to the Penn website. They can pick one of our surgical providers. They can always contact the surgeon directly. If they don't want to do that, or they want to have their patients call. We have a couple of 1-800-NUMBERS set up. It's important to know that we are not expecting the cardiologist or the primary care doctor to know who's going to be the best surgeon for whatever their patient has. And that's what our nurse practitioners do. We review all the new patients coming in, we find the best surgeon.

We call the patients ahead of time to see what their expectations are, and we help get them into those clinics. And I can be emailed at Penn BAV at pennmedicine.upenn.edu. I do want to point out that we not only see patients in the downtown Presbyterian and at the Perlman Center, but we also see patients in our suburban satellite office in Radner, if that's more convenient for patients.

Host: You can reach the Penn Aorta Center at 877-937-7366. For the Bicuspid Aortic Disease Center, it would be 877-736-6228.

I'd love you to offer your final thoughts for other providers and referring physicians and what you would like them to know about the important work provided by advanced practice providers and the surveillance clinic at Penn Medicine.

Melanie Freas, DNP, CRNP: So I think it's important for our providers to understand that aortic disease is a chronic disease, especially if we're talking about aortic dissection. This is a lifelong disease process that these patients are going to have to live with. Our surveillance clinics are really patient-focused.

We take the time to provide education. We provide answers to their questions. Simple things like, what exercises can I do? How can I live my life moving forward? We have a very large population of young women with bicuspid aortic valves who have to make decisions about surgery, but also know that in the future they're going to have to make decisions about their family, whether or not they're going to have children. So it is a very trusting atmosphere for our patients. Lots of education. I just think it's a wonderful opportunity for me as a provider to get to know my patients and their families very well, and they just feel much more confident going into surgery.

Host: Thank you so much, Melanie, for joining us today and, and really giving us such great information for other providers. And to refer your patient to Melanie Freas at the surveillance Clinic at Penn Medicine, please call our 24/7 provider-only line at 877-937-PENN, or you can submit your referral via our secure online referral form by visiting our website at pennmedicine.org/referyourpatient.

That concludes this episode from the Specialists at Penn Medicine. I'm Melanie Cole.