Care Delivery ry Jody Hereford, MS, BSN, MS Past President AACVPR - - PowerPoint PPT Presentation

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

• verall quality of life.
• It is safe and beneficial when patients are evaluated and

appropriately selected.

Traditional Cardiac Rehabilitation (TCR) Multidisciplinary Team Approach

• Medical Director
• Referring Physician
• Registered Nurse
• Exercise Physiologist
• Registered Dietitian
• Respiratory Therapist
• Behavioral Specialist
• Physical Therapist
• Occupational Therapist
• Health Educator
• Pharmacist
• 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)
• r 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

• r 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!

• 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

Eeeeeeeeek 2!

Common Barriers to CR Referral, Enrollment, & Participation

• Patient-level Factors

– Distance from center – Lack of transportation – Financial constraints, including high co-pays – Time off from work – Limited motivation

• Provider- level Factors

– Awareness of guidelines – Unsure how to refer, and/or difficult to refer

• Program-level Factors

– Days/hours of operation – Scarcity of programs – Wait lists and delays – Financial viability

• System-level Factors

– Organizational dynamics, leadership buy-in – Complexity of programs – 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 Past

– Predominately FFS reimbursement model – Acute care focus – Fragmented delivery systems and care – Limited consumer options for improving health and well being

The Future

– Pay for value, bundled payments, episodes of care, APMs – Post Acute Care Continuum & focus – Population Health, Care Coordination, Longitudinal Care, Collaborative Care – Opportunity to build alignment and 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 –Aspirin for secondary prevention –Blood pressure control –Cholesterol management –Smoking cessation

Outcomes that MATTER!

Lives Saved

26,000

per year Hospitalizations Prevented

97,000

per year What if we were able to achieve a 70% participation rate in Cardiac Rehabilitation?

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

Potential Disadvantages of Home-Based CR

• Lack of reimbursement
• Less intensive exercise training
• Lower social support
• Less patient accountability
• Lack of standardization among programs
• Minimal patient monitoring
• Safety concerns for sicker patients

Components of Home-Based CR Program (S (Summary ry)

• Automatic referrals (post-CABG, post-PCI order sets)
• Bedside visit by cardiac rehabilitation nurse
• Exercise prescription and physical activity monitoring
• Motivational interviewing and goal setting
• Provision of home exercise equipment (if needed)
• Medication reconciliation and tracking
• Nutrition and weight management
• Stress reduction (including peer support group calls)
• Risk factor management (blood pressure, lipids, smoking)

Slide credit to Ana Mola, PhD, RN, ANP-C, MAACVPR

Slide credit to Ana Mola, PhD, RN, ANP-C, MAACVPR

Slide credit to Ana Mola, PhD, RN, ANP-C, MAACVPR

Findings & Preliminary Outcomes

• Decreased readmission rate
• Decreased ER use
• Improved recognition of symptoms
• Improved self care management
• Symptom reduction and improved symptom management
• Improved self care confidence

Feinberg, et al. A Mixed Methods Evaluation of the Feasibility and Acceptability of an Adapted Cardiac Rehabilitation Program for Home Care Patients. 2017.

Thank you.

Jody Hereford, MS, BSN, RN P.O. Box 1406 Boulder, CO 80306 (303) 885-9754 Cell (303) 544-0007 Office jodyhere@jodyhereford.com www.jodyhereford.com

Cardiac Rehabilitation Telligen Page 1 of 4 www.jodyhereford.com

Cardiac Rehabilitation: Reimagining and Retooling Care Delivery

Jody Hereford, MS, BSN, RN, MAACVPR

References and Resources

References that support the clinical and health benefits and cost-savings of CR

• 1. Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-Based

Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol. 2016;67:1-12.

• 2. Dunlay, Shannon M. et al. Participation in Cardiac Rehabilitation, Readmissions, and Death After

Acute Myocardial Infarction. Am J Med. 2014; 127(6):538-546.

• 3. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and

long-term risks of death and myocardial infarction among elderly Medicare beneficiaries.

• Circulation. 2010 Jan 5;121(1):63-70.
• 4. Suaya J, Stason W, Ades P, et al. Cardiac Rehabilitation and Survival in Older Coronary Patient. J

Am Coll Cardiol. 2009;54(1):25-33. doi:10.1016/j.jacc.2009.01.078.

• 5. O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with

chronic heart failure HF-ACTION Randomized Controlled Trial. JAMA 2009;301:1439-1450.

• 6. Keteyian SJ, Leifer ES, Houston-Miller N, et al. Relation between volume of exercise and clinical
• utcomes in patients with heart failure. J Am Coll Cardiol. 2012;60:1899-1905.
• 7. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med.

2001;345:892-902

• 8. Doll JA, Hellcamp A, Thomas L, et al Effectiveness of cardiac rehabilitation among older patients

after acute myocardial infarction. Am Heart J 2015;170:855-864.

• 9. Shah ND, Dunlay SM, Ting HH, et al. Long-term medication adherence after myocardial infarction:

experience of a community. Am J Med. 2009 Oct;122(10):961.e7-13.

• 10. Stahle A, Mattsson E, Ryden I, et al. Improved physical fitness and quality of life following

training of elderly patients after acute coronary events. Eur heart J. 1999;20:1475-1484.

• 11. Pasquali SK, Alexander KP, Coombs LP, et al. Effect of cardiac rehabilitation on functional
• utcomes after coronary revascularization. Am Heart J. 2003;145:445-451.
• 12. Blumenthal JA, Babyak MA, O’Connor C, et al. Effects of exercise training on depressive

symptoms in patients with chronic heart failure. JAMA 2012;308:465-474.

• 13. Blumenthal JA, Sherwood A, Babyak MA, et al. Exercise and pharmacological treatment of

depressive symptoms in patients with coronary heart disease: results from the UPBEAT (Understanding the Prognostic Benefits of Exercise and Antidepressant Therapy) study. J Am Coll Cardiol 2012; 60: 1053-63.

• 14. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary

heart disease. Circulation. 2005;111:369-376.

Cardiac Rehabilitation Telligen Page 2 of 4 www.jodyhereford.com

CR Guidelines and Evidence

• 1. AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 5th Edition,

2013.

• 2. ACSM Guidelines for Exercise Testing and Prescription, 9th Edition, 2014.
• 3. Thomas RJ, King M, Lui K, Oldridge N, Pina I, Spertus J. AACVPR/ACCF/AHA 2010 Update:

Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services. Circulation. 2010;122:1342-1350.

• 4. Gary J. Balady, Mark A. Williams, Philip A. Ades, Vera Bittner, Patricia Comoss, JoAnne M.

Foody, Barry Franklin, Bonnie Sanderson, Douglas Southard. AHA/AACVPR SCIENTIFIC

• STATEMENT. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007

Update A Scientific Statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.

• Circulation. 2007;115:2675-2682
• 5. Larry F. Hamm, PhD, FAACVPR, Chair; Bonnie K. Sanderson, PhD, RN, FAACVPR; Philip A. Ades,

MD, FAACVPR; Kathy Berra, MSN, ANP, FAACVPR; Leonard A. Kaminsky, PhD; Jeffrey L. Roitman, EdD; Mark A. Williams, PhD, FAACVPR. Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 2010 Update POSITION STATEMENT OF THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION. Journal of Cardiopulmonary Rehabilitation and Prevention 2011;31:2–10.

• 6. Sidney C. Smith, Emelia J. Benjamin, Robert O. Bonow, Lynne T. Braun, Mark A. Creager, Barry A.

Franklin, Raymond J. Gibbons, Scott M. Grundy, Loren F. Hiratzka, Daniel W. Jones, Donald M. Lloyd-Jones, Margo Minissian, Lori Mosca, Eric D. Peterson, Ralph L. Sacco, John Spertus, James

• H. Stein, Kathryn A. Taubert. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for

Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update. A Guideline From the American Heart Association and American College of Cardiology Foundation. https://doi.org/10.1161/CIR.0b013e318235eb4d. Circulation. 2011;124:2458-2473. Originally published November 3, 2011

New Models of Care and Home Based Cardiac Rehabilitation

• 1. Sandesara PB1, Lambert CT1, Gordon NF2, Fletcher GF3, Franklin BA4, Wenger NK1, Sperling L5.

“Cardiac rehabilitation and risk reduction: time to "rebrand and reinvigorate". J Am Coll

• Cardiol. 2015 Feb 3;65(4):389-95.
• 2. Gary J. Balady, Philip A. Ades, Vera A. Bittner, Barry A. Franklin, Neil F. Gordon, Randal J.

Thomas, Gordon F. Tomaselli, Clyde W. Yancy. A Presidential Advisory From the American Heart Association. Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and Beyond. Circulation. 2011;124:2951-2960

Cardiac Rehabilitation Telligen Page 3 of 4 www.jodyhereford.com

• 3. Ades PA1, Keteyian SJ2, Wright JS3, Hamm LF4, Lui K5, Newlin K6, Shepard DS7, Thomas RJ8.

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. 2017 Feb;92(2):234-242. doi: 10.1016/j.mayocp.2016. 10.014. Epub 2016 Nov 15. https://www.ncbi.nlm.nih.gov/pubmed/27855953

• 4. Taylor RS, Dalal H, Jolly K, Zawada A, Dean SG, Cowie A, Norton RJ. Home-based versus centre-

based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD007130.

• 5. Kelly L. Russell, MSc; Tanya M. Holloway, MSc; Margaret Brum, BASc; Veola Caruso, RN; Caroline

Chessex, MD; Sherry L. Grace, PhD. Cardiac Rehabilitation Wait Times: Effect on Enrollment. Journal of Cardiopulmonary Rehabilitation and Prevention 2011;31:373-377.

• 6. Feinberg, J.L., Russell, D., Mola, A., Trachtenberg, M., Bick, I., Lipman, T.H., Bowles, K.H. (2017).

A Mixed Methods Evaluation of the Feasibility and Acceptability of an Adapted Cardiac Rehabilitation Program for Home Care Patients.: Geriatric Nursing. Accepted 8/23/17

• 7. Feinberg JL, Russell D, Mola A, Bowles KH, Lipman TH. Developing an Adapted Cardiac

Rehabilitation Training for Home Care Clinicians: Patient Perspectives, Clinician Knowledge, & Curriculum Overview. J Cardiopulm Rehabil Prev. Vol. 37, No. 6, November 2017. Published

• nline first December 28, 2016. doi: 10.1097/ HCR.0000000000000228.

Websites of Note

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Promoting health and preventing disease. http://www.aacvpr.org  AACVPR Program Directory Searchable cardiac rehabilitation program directory https://www.aacvpr.org/Resources/Program-Directory  AACVPR Roadmap to Reform (R2R) In front of us is an excellent opportunity for CR professionals to reform programs to enhance patient participation, individualize treatment, explore new methods of delivery, and confirm the efficacy of CR in reducing the impact of cardiovascular disease. http://www.aacvpr.org/R2R  AACVPR Evidence Based Benefits of Cardiac Rehabilitation https://www.aacvpr.org/Portals/0/Advocacy/Evidence%20of%20Benefits%20of%20Cardiac%20 Rehabilitation_Revised%20September%202016.pdf  AACVPR Cardiac Rehabilitation Fact Sheet https://www.aacvpr.org/Portals/0/Resources/Marketing%20CR%20Resources/AACVPR_CR_Fact _Sheet.pdf

Cardiac Rehabilitation Telligen Page 4 of 4 www.jodyhereford.com

Million Hearts Launched in 2012, the national initiative—alongside 120 official partners and 20 federal agencies— successfully aligned national cardiovascular disease prevention efforts around a select set of evidence- based public health and clinical goals and strategies. As a result, significant progress was made toward the audacious aim to prevent a million cardiovascular (CV) events in five years. https://millionhearts.hhs.gov/ American Heart Association MI Toolkit Access and Download the Acute Myocardial Infarction Toolkit The American Heart Association developed the Acute Myocardial Infarction (AMI) toolkit for providers to use as a resource to engage their patients after a heart attack and empower them with the resources that will assist as they embark on their recovery journey. Within the AMI Toolkit you will find resources such as the ones listed below and many other relevant tools to help supplement your work. Please reach out to oge.okeke@heart.org for more information or questions.  AMI Toolkit: http://www.heart.org/HEARTORG/Conditions/HeartAttack/Acute-Myocardial- Infarction-Toolkit_UCM_487847_SubHomePage.jsp  The Patient-Centered Communication Guide: http://www.heart.org/idc/groups/heart- public/@wcm/@hcm/documents/downloadable/ucm_488767.pdf  The Heart Attack Discharge Worksheet: http://www.heart.org/idc/groups/heart- public/@wcm/@hcm/documents/downloadable/ucm_465303.pdf  Heart Attack Education Infographic: http://www.heart.org/idc/groups/heart- public/@wcm/@hcm/documents/downloadable/ucm_487881.pdf Home Heart Health A program to ensure cardiac patients receive the rehabilitative support they need where they are most comfortable: in their homes and communities. Our goal is to design standardized, evidence-based guidelines and implement a patient- driven home- based cardiac rehabilitation model. . http://www.homehearthealth.org/