Cardiac Rehabilitation: Reimagining and Retooling Care Delivery ry Jody Hereford, MS, BSN, MS Past President AACVPR (American Association of Cardiovascular & Pulmonary Rehabilitation)
Cardia iac Rehabil ilitation: Reim imagining and Retoolin ing Care Deliv livery Learner Obje jectives • Describe the significant benefits and outcomes of CR participation especially in this changing time of health care payment and delivery. • Articulate the Core Components of CR. • Identify current challenges, barriers to participation, and predictors of underutilization. • Explore new models of care delivery and discuss opportunities to expand the reach and impact of CR.
References and Resources A Quick Review
“Cardiac rehab doesn’t change your past, but it can help you improve your heart’s future.” American Heart Association, 2016
What is Cardiac Rehabilitation (CR)? • A comprehensive risk reduction program for people living with heart disease designed to reduce the risk of subsequent heart attacks and death from other causes. • The primary goal of cardiac rehabilitation is to enable the participant to achieve his/her optimal physical, psychological, social and vocational functioning through exercise training and lifestyle/behavior change. – CR is a comprehensive program of exercise, education, and behavior change. – CR is designed to control symptoms, improve exercise tolerance, and improve overall quality of life. • It is safe and beneficial when patients are evaluated and appropriately selected.
Traditional Cardiac Rehabilitation (TCR) Multidisciplinary Team Approach • Medical Director • Behavioral Specialist • Referring Physician • Physical Therapist • Registered Nurse • Occupational Therapist • Exercise Physiologist • Health Educator • Registered Dietitian • Pharmacist • Respiratory Therapist • Other consulting practitioners
Strong Evidence of Benefits: Participation in early outpatient CR results in: – Reduced all-cause mortality ranging from 12%-24% 1-7 – Reduced cardiac mortality from 26%-31% 1-7 – Reduced readmission rates to hospital 1,2,5,6 – A strong dose-response relationship between number of CR session and long-term outcomes 3,4,8 – Improved adherence with preventive medications 9 – Improved function and exercise capacity 7,10,11 – Improved mood and quality of life 10,12,13 – Improved modifiable risk factors 7,11,14
Referral to Cardiac Rehabilitation is a Class 1 Indication in AHA/ACC Clinical Guidelines: • Myocardial Infarction • Percutaneous Coronary Intervention • Coronary Bypass Grafting • Chronic stable angina • Heart failure • Peripheral arterial disease • Cardiovascular prevention in women
Furthermore: • Referral to CR is included in ACC/AHA Performance Measure Sets for: – Coronary Artery Disease – Myocardial Infarction – Percutaneous Intervention • Referral to CR is included in ACC/AHA Registries – PINNACLE – Cath/PCI – ACTION – STS – GWTG • Referral to CR is included in QPP (began in PQRS) as a quality measure
Current CMS TCR Coverage • CR programs may be provided in a hospital outpatient setting (including a critical access hospital) or in a physician office. • Physicians responsible for CR/ICR programs are identified as medical directors who oversee or supervise the CR/ICR program at a particular site. The medical director, in consultation with staff, is involved in directing the progress of individuals in the program. • All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when items/services are being furnished under the program • A participant must be referred by an MD or DO. • Covered diagnoses currently include: – Acute Myocardial Infarction (AMI) within the last 12 months – Coronary artery bypass surgery (CABG) – Current stable angina pectoris – Heart valve repair or replacement – Percutaneous Transluminal Coronary Angioplasty (PTCA) or coronary stenting – Heart or heart-lung transplant – Stable chronic heart failure
Stable, Chronic Heart Failure • Patients with left ventricular ejection fraction (LVEF) of 35% or less, and • New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks (Effective February 18, 2014). • Stable patients are defined as patients who have not had recent (=6 weeks) or planned (=6 months) major cardiovascular hospitalizations or procedures.
Underutilization! Despite its clear benefits, CR remains greatly underutilized. Evidence clearly shows that the more sessions patients attend, the better their outcomes and the lower their risk for heart attack and mortality compared with those who do not participate. – Of three million Americans who become eligible for cardiac rehabilitation (CR) every year, only 20% enroll and a mere 3.3% fully complete CR programs nationwide. – Of eligible patients, only 19-34% of heart attack survivors and approximately 31% of patients after CABG participate in cardiac rehabilitation – Participation is lowest in women, minorities, socio-economically disadvantaged patients, and the elderly JA Suaya, DS Shepard, ST Normand, PA. Ades, J Prottas, WB Stason. Use of Cardiac Rehabilitation by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery. Circulation 2007;116;1653-1662
Eeeeeeeeek! • REFERRAL – Only ~20% of eligible candidates are referred to cardiac rehab programs • ENROLLMENT – Only ~34% of those referred actually enroll • COMPLETION – Only ~ 49% of participants complete the traditional cardiac rehab program – Resulting in only 3.3% achieving full-benefit from traditional cardiac rehab!
Eeeeeeeeek 2! • There is an additional gap in time to treatment. • The median wait time from discharge from the hospital to entry into a program is 42 days. • For every one day in wait time, patients are 1% less likely to enroll. Cardiac Rehabilitation Wait Times: EFFECT ON ENROLLMENT. Russell, Holloway, Brum, Caruso, Chessex, Grace. JCRP, 2011;31:373-377
Common Barriers to CR Referral, Enrollment, & Participation • Patient-level Factors • Program-level Factors – Distance from center – Days/hours of operation – Lack of transportation – Scarcity of programs – Financial constraints, including – Wait lists and delays high co-pays – Financial viability – Time off from work • System-level Factors – Limited motivation • Provider- level Factors – Organizational dynamics, leadership buy-in – Awareness of guidelines – Complexity of programs – Unsure how to refer, and/or difficult to refer – Poor reimbursement
Disparities in Access TCR Participation is lowest in: • Older patients • Women • Members of minority populations • Lower SES • Lower levels of education • English is not their primary language • AND Balady, et al. Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and Beyond, 2011.
Disparities: Impact! • Often have a higher burden of comorbidities and cardiac risk factors • Lower health literacy and numeracy • Less disease self management skills • MUCH less likely to be referred to CR/SPP • Less likely to enroll after referral • Patients in these groups who complete CR/SPP benefit in clinical, behavioral, and health domains. However, they may not always do so to the same degree as other enrollees.
Methods to Facilitate CR Referral, Enrollment, & Participation • Include referral to CR/SPP in the hospital discharge plan • Automated referral through the EMR • Providing patients with a choice of CR/SPP to attend • Ensure that patients are aware of and agree to the referral • Arrange a personal visit from the CR/SPP liaison • Providing transportation and parking assistance if required • Following up with those referred but not yet enrolled • “See you in 7” campaigns • Group orientation visits • Open gym concepts • Women only offerings
Bridge to our Future The Future The Past – Pay for value, bundled payments, – Predominately FFS episodes of care, APMs reimbursement model – Post Acute Care Continuum & focus – Acute care focus – Population Health, Care – Fragmented delivery systems and Coordination, Longitudinal Care, care Collaborative Care – Limited consumer options for – Opportunity to build alignment and improving health and well being partnerships with the community and patients – Focus on HEALTH Transform the past while creating the future
New Models of Care Delivery To expand the reach and impact of cardiac rehabilitation.
> 70% Performance on ABC’S – A spirin for secondary prevention – B lood pressure control – C holesterol management – S moking cessation
Outcomes that MATTER! What if we were able to achieve a 70% participation rate in Cardiac Rehabilitation? Lives Saved Hospitalizations Prevented 26,000 97,000 per year per year Source: Dr. Phil Ades, MD
Potential Advantages of f Home-Based CR • No wait list/capacity issues • Customizable and individually tailored • Flexible scheduling • No travel/transportation issues • Greater privacy • Lower cost • Integrated with patient’s regular home routine • Possibly greater adherence and sustainability
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