Thursday, August 27, 2020 | Terri McDonald
Exercise-based cardiac rehabilitation (CR) has been a Class I indication in clinical guidelines for patients with chronic stable angina, ST-segment MI, non-ST-segment MI, and patients undergoing percutaneous coronary intervention and coronary artery bypass surgery for more than a decade. Most recently it has been added as a Class I indication for heart failure and lower extremity peripheral arterial disease. Enrolling patients and coaching them to completion of a CR program can reduce the risk of death from future cardiac events and all-cause mortality. The benefits are well documented – we can reduce odds of mortality more than 50% with this intervention when compared to patients who don’t complete CR (American Heart Association). It can also improve risk factors, functional status, quality of life and mood and keep patients out of the hospital. Simply stated, we could save lives, improve patients’ quality of life and reduce costs to the healthcare system if we coach our patients to enroll in and complete CR.
Yet, incredibly, only a fraction of eligible patients in the U.S. enroll in a CR program after a major cardiovascular event or diagnosis. In a study assessing Medicare enrollee demographics in 2016-2017, 18.9% of eligible women and 28.6% of eligible men enrolled in Phase II CR. In addition to the gender disparity, the study reflects a disturbing pattern of disparity in access for minority enrollment, with 13.6% of eligible non-Hispanic blacks, 13.2% of eligible Hispanics, and 16.3% of eligible Asians enrolled in 2016-2017 (Ritchey, 2020). Recognizing the magnitude of this issue pre-pandemic gives perspective to the challenges we now face to assure CR is not erased as a means to improve the cardiovascular health of the communities we serve.
The Referral – Enrollment Gap
Historically, hospital-based CR programs provided Phase I CR in the inpatient setting. In this model, a member of the CR team met with the patient, provided vital information about their event or diagnosis, and often assisted with initiating a walking program prior to discharge. The pre-discharge connection was an excellent means to improve the chances of the patient moving forward to Phase II enrollment in a center-based program. Unfortunately, over time budget constraints have eliminated the Phase I program in most hospitals. Disease management education has fallen to the bedside nurse and early ambulation to the physical therapy teams. As length of stays have shortened and the nursing and physical rehab teams have become more stretched, the focus on early ambulation and education about a home walking/exercise program has diminished. In a current typical situation, the patient may receive brief education about CR prior to discharge. Optimistically, we might expect a patient to retain about half of the information they receive on the day of discharge. Without follow-up coaching and clear direction from the cardiovascular provider, providing anecdotal information about the benefits of CR in the chaos of the discharge process will not be enough to push patients toward the option to enroll in a CR program.
As a performance measure in the NCDR and STS registries the percentage of eligible patients referred to CR prior to hospital discharge has gained a lot of attention over the past several years. It may be used as one of the measures physician practices select for the Merit-based Incentive Payment System. It also plays a role in the requirements for center of excellence designation for some large commercial payer plans. As is often the case, we have responded to a process-based measure by implementing lots of process-based tools, like automated orders embedded in post-procedure order sets, discharge order sets, or encounter templates. However, does the simple act of referral impact the likelihood of enrollment? The answer is likely no – except in highly motivated patients. Although there was no direct correlation to use of CR, a recent survey of more than 2,400 adults revealed that 53% did not feel the additional steps needed to improve their health were easy to understand after talking with their doctor (MOBE, 2020). Prescribing CR should be viewed with the same importance as prescribing other Class I recommendations. This will require attention to follow-up and follow-through with our patients – in doing so the effort invested in getting patients enrolled in CR will substantially increase the odds of their compliance with all of the secondary prevention measures we prescribe.
Overcoming Barriers to Enrollment
As we address the structures in the practice setting to promote enrollment there are a number of socioeconomic barriers to deal with. Health plan coverage, co-pay, patients’ commitment to follow-through, travel, and now the pandemic – quite possibly the most crushing blow to the traditional CR model. All of these barriers can be overcome using the same approach we use to push patients forward for other evidence-based therapies. One way is to make CR enrollment an expectation for the members of your team dedicated to facilitating other therapies. Often these team members even assist patients to locate social or financial resources that support access to the care and therapies prescribed by the cardiologist or CT surgeon.
On the cardiovascular service line front there may be a focus on restarting services in the wake of the pandemic based on the level of margin they provide in turn displacing CR from the list of priorities and creating an access issue for patient enrollment. Moving back to an episodic, intervention-focused model will set back our collective vision for improving the cardiovascular health of our communities. To prevent CR programs from languishing or even disappearing we need to be creative and innovative, possibly moving away from traditional, center-based CR models. Evolving models of virtual CR or hybrid models using remote patient monitoring technology can offer solutions to reduce overhead, improve efficiencies, and address issues created by social distancing guidelines.
Steps to Optimize CR Access and Enrollment
First, ask these questions:
If your program is like most in the U.S. the numbers will be low. Set goals to achieve improvements by hardwiring referral and enrollment. Develop patient education about CR as a means to provide clear direction about the steps needed to make crucial lifestyle changes. Show how CR is equally as important as other interventions to reduce the chance of future events and the risk of mortality or disability.
Next, evaluate the infrastructure of your current CR program. If team members are displaced due to volume, consider dedicating some portion of a full-time equivalent to serve in a Phase I role. This role could help providers coach and guide the patient to enrollment in Phase II and possibly with follow-up to encourage completion.
Finally, assess the possibility of using virtual resources to meet patients where they are, a hybrid model, or even outsourcing the service altogether. It’s a strange and frightening time for healthcare, but it’s also a time of incredible innovation. Don’t let CR slip off the list of priorities as we define our new normal.
Read more on this topic in parts 2 & 3:
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Illustration: Lee Sauer
Terri McDonald, RN, MBA, CPHQ is Vice President, MedAxiom Consulting. She brings extensive knowledge and experience in leading, managing and optimizing every level of the cardiovascular service line. Following a clinical career in cardiac and critical care nursing, Terri gained a diverse knowledge of administrative, operations and clinical nursing management in the acute care setting. As VP of Consulting Terri fulfills her lifelong passion for cardiology and cardiovascular care helping her clients succeed through understanding challenges and designing collaborative, practical solutions using evidence-based guidelines and emerging technologies.
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