THE FUNDAMENTALS OF SETTING UP A CARDIAC REHABILITATION PROGRAM.“ Do’s and Dont’s “

ANTONIO S. SIBULO Jr.MD,FPCC,FAsCC,FACC

St.Luke’s Heart Institute

What is Cardiac Rehabilitation?

Cardiac rehabilitation is a medically supervised program designed to optimize a cardiac patient’s physical, psychological, and social function.

In addition, it aims to stabilize, slow or even reverse the progression of the underlying atherosclerotic processes, thereby reducing death and disability.

Why Run a Cardiac Rehabilitation Program? It is recognized as an integral component of

the continuum of care for patients with cardiovascular disease. Its application is a Class I Recommendation in most contemporary cardiovascular clinical practice guidelines.

J Am Coll Cardiol 2008;51:1619–31

Participating in a cardiac rehabilitation (CR)program after a cardiac event yields well-established benefits in reducing cardiac and non-cardiac mortality as well as reducing morbidity and cardiac risk factors . Taylor AS et.al Am J med 2004;116:682-92

Why Run a Cardiac Rehabilitation Program?

Because of this mounting evidence, a number of health care organizations have endorsed the use of CR services in persons with CVD by including provisions for CR in their practice guidelines and position papers. AACPVR/ACC/AHA 2007 Performance measures on Cardiac Rehabilitation for

Referral to and Delivery of cardiac Rehabilitation/Secondary Prevention Services

What are the benefits of Cardiac Rehabilitation?

The benefit is thought to be mediated by several factors, including:

Benefits of exercise training Psychological benefits of group support

and counseling Improved adherence to preventive

therapies Improved control of cardiovascular risk

factors.

What are the demonstrated benefits of Cardiac Rehabilitation?

A 20-30% reduction in all-cause mortality rates Decreases mortality up to 5 years post participation Reduced symptoms (angina, dyspnea, fatigue) Reduction in nonfatal recurrent myocardial over median follow-up of 12 months Improves adherence with preventive medications Increased exercise performance Improved lipid panel (total cholesterol, HDL, LDL ,

and triglycerides)

What are the demonstrated benefits of Cardiac Rehabilitation?

Increased knowledge about cardiac disease and its management Enhanced ability to perform activities of daily livingImproved health-related quality of lifeImproved psychosocial symptoms (reversal of anxiety and depression, increased self-efficacy) Reduced hospitalizations and use of medical resourceReturn to work or leisure activities

Evidence Supporting Cardiac Rehabilitation

Cardiac rehabilitation is now a Class I Indication in clinical guidelines for:

Myocardial infarction (MI)

Percutaneous Coronary Intervention (PCI)

Coronary artery bypass grafting (CABG)

Angina

Heart failure

Valvular heart disease

Peripheral arterial disease (PAD)

Group of Patients who will Benefit from CaRe

Patients with a history of: Myocardial infarction (heart attack) Coronary artery bypass graft surgery (CABG) Current stable angina pectoris Heart valve repair or replacement Percutaneous transluminal coronary angioplasty

(PTCA)/ or coronary stenting Heart or heart-lung transplant Heart Failure and those with ventricular assist devices Coronary artery disease equivalents such as diabetes

or peripheral artery disease Patients with diabetes Peripheral arterial disease

Components of Cardiac Rehabilitation (4)

1. Physician prescribed exercise

Exercise training and other therapeutic exercise including aerobic and strength training.

An Individualized Treatment Plan (ITP) is a required element that describes the individual’s diagnosis, the type, amount, frequency and duration of the items and services under the plan and the goals set for the individual under the plan. The plan is written, established, reviewed, and signed by a physician every 30 days.

Components of Cardiac Rehabilitation

2. Cardiac risk factor modification Includes education, counseling, and behavioral

intervention; related to the individual’s care and tailored to the individual’s needs.

It may include a combination of one or more of the following. Physical Activity

Nutrition Lipid management Blood pressure management Smoking cessation Weight management Diabetes management

Psychosocial management

Components of Cardiac Rehabilitation

3. Psychosocial Assessment Evaluation of the individual’s mental and

emotional functioning as it relates to the individual’s rehabilitation or cardiac condition.

4. Outcomes AssessmentEvaluation of the patient’s progress as it

relates to the individual’s rehabilitation goals and program.

Education, counselling and behavioral interventions

CONSIDER ORGANISATIONAL CONSIDER ORGANISATIONAL ASPECTSASPECTSLOCATION

Gym/Fitness Center

EQUIPMENT

Bicycle/Arm Ergometer Treadmill Stepper Rowing machine Free weights 12 Lead ECG machine Cardiac defibrillator/AED

Organizational Issues

Cost savings and Cost effectiveness

In setting up a care program- Do’s

In your efforts, target your community at large. Be sure to include hospital administrators, physicians, coworkers, and current patients.

Advertise your program through your in-house newsletters and bulletins.

Arrange for interviews on radio or local news magazine shows to publicize your hospital’s program. Provide specific information on heart disease prevention and rehabilitation.

Sponsor an educational program or seminar for health professionals. Make your special events fun and educational. Offer risk factor assessments, smoking cessation clinics, heart-healthy cooking classes, etc.

Promote your program through Publicity and Advertising

In setting up a care program- Do’s

The Staff should be committed to treating each patient as a unique individual with special needs and concerns.

Ensure that systems are present to obtain the clinical informations so that the CaRe team can develop an appropriate patient-centered treatment plan that prioritize goals and outlines intervention strategies for exercise training, tactics to reduce cardiovascular disease risk and a follow-up plan that reflects progress towards goals.

Individualize Evaluation and Goal development for every patient

In setting up a care program- Do’s

• Results of recent cardiac tests including

TET,ECG,2DE• Status of cardiopulmonary ,orthopedic and neuromuscular system, cognitive function• Detailed review of CV risk factors• Complete list of medications• Patient specific symptoms of angina or its equivalents• Comorbid conditions with attention to their impact on exercise, adherence and disease progression• Pertinent psychosocial and occupational history

Individualize Evaluation and Goal development for every patient

In setting up a care program- Do’s

Clinicians should consider instituting processes that encourage referral of appropriate patients to CARE. In addition, it is important that referring healthcare practitioners and CARE teams communicate in ways that promote patient participation

Implementation of standing referral orders to CARE based on eligible diagnoses supported by clinician guidelines. These “systematic” strategies are implemented manually or may be autumativally using discharge order sets in medical records.

Device Strategies to improve Referrals

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In setting up a care program- Do’s

“liaison” strategies- in which a healthcare provider or peer mentor speaks to the patient at the bedside about CARE and facilitates referral while permitting discussion of the nature and merits of such programs and potential barriers to participation.

Dissemination of patient education materials or motivational letters both designed to augment CARE utilization.

Grace SL et al. Referral to and discharge from cardiac rehabilitation: Key informant views on continuity of care. Presented at the University Health Network Annual Research Day. Toronto, ON:2003.

Device Strategies to improve Referrals

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In setting up a care program- Do’s

Device Strategies to improve Referrals

Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization rates. Arch Intern Med 2011; 171:235-241.

“Automatic“- in which the patient would be sent a letter detailing the clinic appointment Liaison- when a healthcare professional would explain the benefits of the program to the patient while they were still in the hospital Combination of the two previous approaches.

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In setting up a care program - Do’s

• Age- younger patients more likely to participate

• Gender difference- female patient less likely to participate

• Financial• Lack of Patient Motivation• Patient work and time conflicts• Lack of Physician support and referral• Distance and transportation

Address the Common Barriers to Cardiac Rehab Participation

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In setting up a care program - Do’s

• The program director should address issues pertaining to reimbursement of services

• Currently, where issues regarding insurance coverage and copayment of services by the patient may hinder referral to cardiac rehab, efforts should be made to incorporate these programs in CV care payment packages to ensure its utilization.

Incorporate CARE Program to packages of CV care to ensure Utilization

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In setting up a care program - Do’s

• Incorporate CaRe Program to packages of CV care to ensure Utilization

Phase of

Cardiac Rehab

Number of inclusive sessions

(8,12,24,36..)

Gross amount

Discounted Amount

Phase I PhaseII Phase III Phase IV

Items inluded in package:

Cardiac rehab serviceStress TestDoctor's FeeDiet Counselling feeTelemetry monitoring

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In setting up a care program - Do’s

Promote Physician and Patient Education with emphasis on Lifestyle changes as an intergral part of secondary prevention strategies

Rehabilitation phase includes patient education sessions regarding lifestyle change, diet and detrimental habits, such as smoking.

Apply specific educational strategies to achieve behavioral change that will address cardiac risk factors and optimize compliance to medication and exercise training.

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In setting up a care program - Don'ts

Don't forget the following:

Close interaction with the patient's primary care provider, cardiologist and cardiovascular surgeon who cares for the the patient's overall cardiovascular health.

Identify high risk patients for closer monitoring and those who need further cardiac work-up

Monitor patient progress toward achieving goals and ensure that patient and program outcomes are consistent with current clinical practice guidelines

Make CARE sessions interesting and promote patient interaction to encourage group support

Exercise Training

Outline Measures of Performance of Care Indices

Why a need for Performance Measures

• Designed as a mechanism to rapidly translate strong clinical evidence into practice

• Provide incentive for rehabilitation referral• Set standards of care

Measures of Performance of Care Indices

• Patient assessment• Nutritional counseling• Weight management• Blood pressure management• Lipid management

Measures of Performance of Care Indices

• Diabetes management• Tobacco cessation• Psychosocial management• Physical activity counseling• Exercise training• Use of preventive medications• Data collection for CARE

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