2/10/2014
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Cardiac Rehabilitation:
Are we Getting the Bang for the Buck?
Terry Thomas RN MSN FNLA FPCNA
Cardiac Rehabilitation:
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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Cardiac Rehabilitation:
Is it the Best Kept Secret in Medicine or
a Missed Opportunity?
Cardiac Rehabilitation:
Is it the Best Kept Secret in Medicine or
a Missed Opportunity?
4Images courtesy of www.google.com
“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.
Miami Baptist CVD Prevention
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
Outcomes = Measured SuccessOutcomes = Measured Success
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
“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
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?”
“Cardiac Rehabilitation:
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
2/10/2014
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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/
InnovationsInnovations
Source: http://online.wsj.com/news/articles/SB10001424127887323514404578650101151932758
2/10/2014
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InnovationsInnovations
Source: http://online.wsj.com/news/articles/SB10001424127887323514404578650101151932758
InnovationsInnovations
Source: http://online.wsj.com/news/articles/SB10001424127887323514404578650101151932758
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
Cardiac Rehabilitation:
Your Partner in Prevention?
Cardiac Rehabilitation:
Your Partner in Prevention?
35Images courtesy of www.google.com
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
Terry Thomas RN MSN
804-836-5091
Cardiac Rehabilitation:
Your Partner in Prevention?
Cardiac Rehabilitation:
Your Partner in Prevention?
38Images courtesy of www.google.com
“If you can identify risk and
motivate them to improve
lifestyle”
Roger Blumenthal, M.D.
Miami Baptist CVD Prevention
2014
“If you can identify risk and
motivate them to improve
lifestyle”
Roger Blumenthal, M.D.
Miami Baptist CVD Prevention
2014
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“Cardiac Rehabilitation:
fit to face the future?”
“Cardiac Rehabilitation:
fit to face the future?”
Clark AM, Redfern J, Briffa T. Heart
Published Online First: June 27 2013 doi:
10.1136/heartjnl-2013-304407
Cardiac Rehabilitation:
Is it a Missed Opportunity?
Cardiac Rehabilitation:
Is it a Missed Opportunity?
41Images courtesy of www.google.com
Cardiac Rehabilitation:
Your Partner in Prevention?
Cardiac Rehabilitation:
Your Partner in Prevention?
42Images courtesy of www.google.com
2/10/2014
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Outcomes = Measured SuccessOutcomes = Measured Success
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”?
2/10/2014
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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
Cost Quality Experience
Reducing per capita costs Improving health status of
populations
Improving individual
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
Reducing per capita costs Improving health status of
populations
Improving individual
experience of care
1. Cost per case?
2. What is the value?
3. Are there more
efficient ways to deliver
services that may
improve quality and
experience?
Goals: The Triple aim
Cost Quality Experience
Reducing per capita costs Improving health status of
populations
Improving individual
experience of care
1. How much do we cost?
− cost/case
1. What is the value we
produce?
2. Are there more
efficient ways to deliver
our services that may
improve quality and
experience?
1. Evidence and science!
2. Who is/are the
‘population(s)?”
3. Care Management
Coordination and the
medical neighborhood
4. Patient engagement,
activation, self
management
2/10/2014
18
Goals: The Triple aim
Cost Quality Experience
Reducing per capita costs Improving health status of
populations
Improving individual
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
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
53
Cardiac Rehabilitation:
Your Partner in Prevention?
Cardiac Rehabilitation:
Your Partner in Prevention?
54Images courtesy of www.google.com
2/10/2014
19
“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
“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
“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
“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
“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
“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