Cardiac Rehabilitation: Are we Getting the Bang for the ... · PDF fileCardiac Rehabilitation: Are we Getting the Bang for the Buck? Terry Thomas RN MSN FNLA FPCNA Images courtesy

2/10/2014

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Cardiac Rehabilitation:

Are we Getting the Bang for the Buck?

Terry Thomas RN MSN FNLA FPCNA


Are we Getting the Bang for the Buck?

Terry Thomas RN MSN FNLA FPCNA

1Images courtesy of www.google.com

Speaker DisclosureSpeaker Disclosure

• I have no relevant commercial relationships to disclose.

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Innovation in Cardiac RehabInnovation in Cardiac Rehab

• Jody Hereford, RN, MS MFAACVPR

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Is it the Best Kept Secret in Medicine or

a Missed Opportunity?


Is it the Best Kept Secret in Medicine or

a Missed Opportunity?


“There is no health care delivery

system akin to cardiac rehab to

assist with behavior change, but

it has limitations”

Alan Rozanski, M.D.

Miami Baptist CVD Prevention

2014

“There is no health care delivery

system akin to cardiac rehab to

assist with behavior change, but

it has limitations”

Alan Rozanski, M.D.


2014

AACVPR National Meeting 2013AACVPR National Meeting 2013

• Detect, Avert and Manage Disease• Integrate a Diabetes Prevention

Model• Collaborate for Improved Patient

Outcomes-”Everyone has Skin in the Game”

• Cardiac Rehab re-design

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Eligible Patient Referral Eligible Patient Referral

• CAD post MI, intervention• Stable angina • CABG • Valve surgery• Heart transplant• Heart Failure 2014

Participation Participation

• Low referral rates -20%• Participation 10-12%• Lower in elderly, indigent,

female and ethnic minorities

Reasons for Low Referral and

Participation

Reasons for Low Referral and

Participation

• Lack of strong physician endorsement• Cost and high copays • Demographic challenges and access• Transportation

• Average national wait time for starting is 42 days

• Limited and inflexible “class times”

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Outcomes = Measured SuccessOutcomes = Measured Success

Health

1. Morbidity

2. Mortality

3. HRQOL

Behavior

(Actions)

Clinical� 20-30% reduction in all-cause

mortality

� Reduces 5-year mortality by 25%-46%

� Decreases recurrent nonfatal

myocardial infarction by 31%

Clinical Outcomes Clinical Outcomes

• Reduced symptoms (angina, dyspnea, fatigue

• Improves medication adherence• Increased exercise performance• Enhanced ability to perform activities of daily

living• Improved health-related quality of life• Improved psychosocial symptoms • Reduced hospitalizations


Health

Behavior

(Actions)

1. Adherence to treatment

2. Health related lifestyle changes

3. Skills for sustained improvements

Clinical

Behavior Change Specialist

Health Coaching

Quality

Cost

Experience

To Impact

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“Consult your

doctor before

starting exercise

program.”

Locate a good cardiologist if

you’re NOT going to start an

exercise program!

Exercise and Safety

Major Cardiovascular Events

Exercise and Safety

Major Cardiovascular Events

• 1/50,000 to 1/120,000 hours of exercise

• 2 Fatalities per 1.5 million patient hours

Leon, A, Franklin B, et al, Cardiac

Rehabilitation and Secondary Prevention of

Heart Disease. Circulation 2005:111:369-376

Meet the FoundersMeet the Founders

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The “Triple Aim” - 2008The “Triple Aim” - 2008

Experience

of care

Health of a

population

Per capita cost

IHI Triple Aim

“I have been saying for more than 15

years that we need a collaborative

integrated system in cardiac

rehab…..They need to get out of the

corner of the 3rd floor area of the

hospital, collaborate and promote their

outcomes”

Wayne Sotile Ph,D., FAACVPR

Miami Baptist CVD Prevention 2014







outcomes”



New Organizational Structures

Accountable Care Organizations (ACOs)

New Organizational Structures

Accountable Care Organizations (ACOs)

In this model everyone becomes accountable to,

and paid for outcomes.

We all have to have skin in the game.

CR

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Landscape of ChangeLandscape of Change

Old System Emerging System

Fee For Service (FFS) Shared Savings Programs (SSP)

Bundling, Episodes, Acute Care Episodes (ACE)

Pay for volume, quantity Pay for value, quality

Pay for admissions, readmissions Penalties, nonpayment

Pay for illness Pay for health

Pay for process Pay for outcome

“Cardiac Rehabilitation:

fit to face the future?”


fit to face the future?”• “Move from rehab to a shared focus on

long term effective disease management and healthy behaviors”

• Term “rehab” is associated with stigma and a dependency

• “Fails to convey long term commitment and behaviors needed for sustained improvements ”

Clark AM, Redfern J, Briffa T. Heart Published Online

First: June 27 2013 doi: 10.1136/heartjnl-2013-304407

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“No outcome- No income”“No outcome- No income”

If the payment today for cardiac rehab was based on payment for outcome would they get paid?

If the hospital/ACO is participating in bundled payments, do they have solid evidence to take a seat at the negotiating table when the value

of your services is evaluated and the distribution of payments is determined?

Jody Hereford RN MS-AACVPR 2013

Medical Director ResponsibilityMedical Director Responsibility

• Individualized Treatment Plan (ITP)

• Specific plan outlines CVD risk reduction

• “Risk stratify for disease progression and likelihood of future cardiac events”

• “Educate staff about emerging concepts in treatment and diagnosis of CVD”

• “Lead team and medical community toward effective changes and continuous improvement”

Source: King, M, Bittner, V et al Medical Directors Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention:2012 Update, Circulation 2012

InnovationInnovation

• Lose the monitors on all or lower risk patients• Open gym concept• Speed coaching-patient engagement• Integrating advanced lab data for risk

stratification• Integrating a diabetes prevention model• Women’s only sessions• Stretch out the program over 6-9 months

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InnovationInnovation

• Work with Health System to focus on population health strategies for employees

• Integrate prevention model with employer sector

• Work with community resources for maintenance program

Residual RiskATHEROGENIC LIPOPROTEINS

Residual RiskATHEROGENIC LIPOPROTEINS

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Cardiac Rehab Population

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Risk for DiabetesINSULIN RESISTANCE

Risk for DiabetesINSULIN RESISTANCE

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Cardiac Rehab Population

InnovationsInnovations

Source: http://online.wsj.com/news/articles/


Source: http://online.wsj.com/news/articles/SB10001424127887323514404578650101151932758

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Essential Elements of SuccessEssential Elements of Success

Old Model New Model

Patients Participants and families

Cardiac and Pulmonary People living with chronic illness

RehabilitationPrevention and Health

Management of Chronic Illness

“Program” System of Services

Waiting list Welcome

Graduation Transition

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Opportunities for Cardiac RehabOpportunities for Cardiac Rehab• Outcomes!

• Incorporate into the Individualized Treatment Plan

– Get the Medical Director involved

• Ability to impact The Triple Aim

– Improve health status of populations

– Cost efficient

– Patient experience

• Opportunity to move beyond "rehab" into prevention and

health management of chronic illness

– Primary through tertiary


Your Partner in Prevention?




Opportunity For

Cardiac Rehab

Centers of Excellence for the

Prevention and Management of Chronic Illness

Opportunity For

Cardiac Rehab

Centers of Excellence for the

Prevention and Management of Chronic Illness

= Improved Individual and

Population Outcomes

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Terry Thomas RN MSN

804-836-5091

[email protected]

Terry Thomas RN MSN

804-836-5091

[email protected]






“If you can identify risk and

motivate them to improve

lifestyle”

Roger Blumenthal, M.D.


2014

“If you can identify risk and

motivate them to improve

lifestyle”

Roger Blumenthal, M.D.


2014

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Clark AM, Redfern J, Briffa T. Heart

Published Online First: June 27 2013 doi:

10.1136/heartjnl-2013-304407


Is it a Missed Opportunity?


Is it a Missed Opportunity?







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Health

1. Morbidity

2. Mortality

3. HRQOL

Behavior

(Actions)

1. Adherence to

treatment

2. Health related

lifestyle changes

3. Skills for sustained

improvements

Clinical

1. BP

2. Lipids

3. Weight

4. A1c

Behavior Change Specialist

Health Coaching

Quality

Cost

Experience

To Impact

A New EraA New EraGoals: The Triple aim

Cost Quality Experience

Reducing per capita costs Improving health status of

populations

Improving individual

experience of care

Cardiac Rehab Programs:Are We Getting the “Bang for

the Buck”?

Cardiac Rehab Programs:Are We Getting the “Bang for

the Buck”?

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Speaker DisclosureSpeaker Disclosure• I have no relevant commercial relationships to

disclose.

• All conflicts of interest of any individuals who control the content of this CME activity, including faculty and members of the Continuing Medical Education Committee and the Continuing Medical Education Department, have been identified and resolved.

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Typical Cardiac RehabTypical Cardiac Rehab

Image courtesy of www.google.com

Goals: The Triple aim



populations


experience of care

1. How much do we cost?

− cost/case

2. What is the value we

produce?

3. Are there more

efficient ways to deliver

our services that may

improve quality and

experience?

1. Evidence and science!!

2. Who is/are our

‘population(s)?”

3. Care Management.

4. Care Coordination and

the medical

neighborhood.

5. Patient engagement,

activation, self

management.

1. Patient Centered

2. More than mere

satisfaction/HCAHPS.

3. May include:

− Interactions

− Perceptions

− Continuum of care,

access, variety

− Culture

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Change the payment

Change the possibilities

Change the payment

Change the possibilitiesOld System Emerging System

Shared Savings Programs (SSP)

Bundling, Episodes, Acute Care Episodes (ACE)

Pay for value, quality

Penalties, nonpayment

Pay for Health

Pay for Outcome

Fee for Service (FFS)

Pay for Volume,

Quantity

Pay for Admissions,

Readmissions

Pay for Illness

Pay for Process

Goals: The Triple aimCost Quality Experience


populations


experience of care

1. Cost per case?

2. What is the value?

3. Are there more


services that may

improve quality and

experience?




populations


experience of care


− cost/case


produce?

2. Are there more



improve quality and

experience?

1. Evidence and science!

2. Who is/are the


3. Care Management

Coordination and the

medical neighborhood


activation, self

management

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populations


experience of care


− cost/case


produce?

3. Are there more



improve quality and

experience?

1. Evidence and science!!

2. Who is/are our


3. Care Management.

4. Care Coordination and

the medical

neighborhood.


activation, self

management.

1. Patient Centered

2. More than mere

satisfaction/HCAHPS.

3. May include:

− Interactions

− Perceptions

− Continuum of care,

access, variety

− Culture

Cardiac Rehab:

Is it Worth the Bang for the Buck?

Cardiac Rehab:

Is it Worth the Bang for the Buck?

• Terry Thomas, RN MSN FNLA FPCNA

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outcomes”









outcomes”









outcomes”









outcomes”









outcomes”



Documents

Cardiac Rehabilitation: Are we Getting the Bang for the ... · PDF fileCardiac Rehabilitation: Are we Getting the Bang for the Buck? Terry Thomas RN MSN FNLA FPCNA Images courtesy