By Todd M. Brown, MD, MSPH, FACC, FAHA, MAACVPR

Just over three years ago, I wrote an article for News & Views about home-based cardiac rehabilitation (CR). The fields of cardiac and pulmonary rehabilitation (PR) have changed dramatically since then. The COVID-19 pandemic has changed how medical care is delivered in the U.S. and has accelerated the implementation of telehealth and other virtual methods of providing care. Although many of the waivers implemented during the public health emergency have expired, CR/PR programs and patients still want to use these technologies. In this article, I hope to update you on where AACVPR stands on these issues and what we’re doing to expand access to CR/PR services.

First, it is important to understand the terminology around how CR/PR services are delivered. The terms telehealth, virtual delivery, home-based and others are often used interchangeably or with different meanings. The Million Hearts^® Think Tank met three years ago to address these very issues. The terminology for three broad care models emerged from discussions in this think tank: in-person, virtual, and remote.¹

• In-person delivery is what you are used to. The patient and the CR/PR professional are physically present, together, in the CR/PR gym in a hospital outpatient department or physician’s office while the CR/PR session is conducted.
• In the case of virtual or remote delivery, the CR/PR professional and patient, who is usually at home, are not physically together. What separates these delivery models is whether the CR/PR professional interacts with the patient in real time (synchronously) during the session or not.
  • With virtual delivery, real-time audio-visual communication technologies are used so that the CR/PR professional can observe and communicate with the patient during the entirety of the CR/PR session.
  • With remote delivery, the patient participates in the session alone, and the CR/PR professional “checks in” or communicates with the patient, asynchronously, at various time points to monitor progress and provide guidance.
  • Both virtual and remote delivery of CR/PR services have established efficacy and safety and are viable options to increase access to CR/PR services at least for patients at low to moderate risk.^2,3

Different, With the Same Foundation

Regardless of whether programs are in-person, virtual, remote or a hybrid of these, all CR/PR programs should have the content and structure of what you know to be CR/PR. Thus:

• Programs should consist of a multidisciplinary team of providers who are led by a physician medical director.
• Patients should undergo a baseline assessment and receive an individualized treatment plan (ITP).
• The ITP must address all of the core components of CR/PR.^4,5 Indications, requirements for session length, direct supervision by physicians (or non-physician providers beginning in 2024) and all other regulatory requirements still apply.

At the conclusion of the program, there should be a completion assessment that includes data collection or key outcomes, just as you currently do in your in-person programs.

Just because the way the services are delivered changes, the content and structure of what is delivered must remain the same.

Leveraging New Models

Although virtual and remote delivery are a means to expand access, it is important to note that traditional, in-person CR/PR delivery has decades of clinical trial and observational data supporting its efficacy and is recommended in numerous multi-societal clinical practice guidelines.^6-14 Thus, in-person CR/PR really is the “tried and true” and preferred method of delivery and should be offered to everyone who qualifies. In addition, it is important to keep in mind that virtual or remote delivery should not necessarily be viewed as replacing in-person delivery or as separate and distinct entities from in-person CR/PR. Rather, these are complementary services. Virtual or remote CR/PR services can serve as an adjunct to in-person CR/PR and can help to enhance the value of in-person CR/PR by providing a way to supervise patients between in-person sessions and perhaps a way to extend the benefits of in-person CR/PR once the in-person portion of the program concludes.

Unfortunately, despite the known benefits of CR/PR, only a minority of eligible patients attend even one session, and even fewer complete the total number of prescribed sessions.^15,16 Improving CR/PR utilization will require a comprehensive and multifaceted approach to first increase utilization of in-person CR/PR services and, secondly, to expand access to virtual and remote delivery to those who are simply unable to attend in-person.

To do your part, you can review the Million Hearts^®/AACVPR Cardiac Rehabilitation Change Package,¹⁷ which has numerous techniques that you can immediately implement in your program to improve efficiencies, expand access, and increase enrollment and adherence in your program. If you are a PR professional, don’t be fooled by the title. Most, if not all, of the techniques highlighted in the Million Hearts^®/AACVPR Cardiac Rehabilitation Change Package can easily be applied to PR programs. So, everyone can find something in the Change Package to improve your program today.

From an advocacy standpoint, AACVPR is supporting two bills to improve access to CR/PR services. The Sustaining Outpatient Services Act (H.R. 955/S.1849) aims to eliminate the reimbursement disparity that exists between hospital-based CR/PR programs that are located off the main hospital campus and those on the main campus. Eliminating this disparity in reimbursement will make it easier for CR/PR programs to move off the main hospital campus to expand and improve access. The Sustainable Cardiopulmonary Rehabilitation Services in the Home Act (H.R. 1406) aims to allow CR/PR programs to deliver services virtually with the use of real-time audio-visual communications technology. As you know, hospital-based CR/PR programs are no longer able to obtain reimbursement from the Centers for Medicare and Medicaid Services for virtual delivery now that waivers from the COVID-19 public health emergency have expired. This bill aims to make this virtual delivery permanent. Unlike hospital-based programs, CR/PR programs located in physicians’ offices are currently able to provide CR/PR services virtually using real-time audio-visual communications technology through the end of 2023 and likely through the end of 2024 as CR/PR services are included as category 3 telehealth services. These category 3 codes are expected to no longer be reimbursed starting in 2025.

It is an exciting time to be in the field of CR/PR. As we emerge from the COVID-19 pandemic, our patients need us now perhaps more than ever. Do your part! Review the Million Hearts^®/AACVPR Cardiac Rehabilitation Change Package today and find one or two techniques that you can immediately implement. Get engaged in AACVPR advocacy efforts by contacting your local congressional member or senator and urge them to support H.R. 955, H.R. 1406 and S. 1849. Lastly, and most importantly, continue to advocate for your patients. At the end of the day, it is your hard work and patient advocacy that make the difference in the lives of the patients that we care for.

Todd M. Brown, MD, MSPH, FACC,  FAHA, MAACVPR, is a cardiologist and Professor of Medicine in the UAB Division of Cardiovascular Diseases, where he is medical director of the cardiac rehabilitation program. He also currently serves as the Director-at-Large on AACVPR’s Board of Directors and was previously AACVPR President from 2017-2018.

References

1. Beatty AL, Brown TM, Corbett M, et al. Million Hearts Cardiac Rehabilitation Think Tank: Accelerating new care models. Circ Cardiovasc Qual Outcomes 2021;14:e008215.
2. Thomas RJ, Beatty AL, Beckie TM, et al. Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J Cardiopulm Rehabil Prev 2019;39:208-225.
3. Uzzaman MN, Agarwal D, Chan SC, et al. Effectiveness of home-based pulmonary rehabilitation: Systematic review and meta-analysis. Eur Respir Rev 2022;31:220076.
4. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. J Cardiopulm Rehabil Prev 2007;27:121-129.
5. Holland AE, Cox NS, Houchen-Wolloff L, et al. Defining modern pulmonary rehabilitation: An official American Thoracic Society workshop report. Ann Am Thorac Soc 2021;18:e12-e29.
6. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol 2022; 79:e263-e421.
7. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. J Am Coll Cardiol 2013;62:e147-e239.
8. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2013;61:e78-e140.
9. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol 2012;60:e44-e164.
10. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. J Am Coll Cardiol 2022;79:e21-e129.
11. Smith SC, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. J Am Coll Cardiol 2011;58:2432-2446.
12. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med 2011;155:179-191.
13. Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of acute exacerbations of COPD: American College of Physicians and Canadian Thoracic Society guideline. Chest 2015;147:892-942.
14. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: A European Respiratory Society/American Thoracic Society guideline. Eur Respir J 2017;49:1600791.
15. Beatty AL, Truong M, Schopfer DW, et al. Geographic variation in cardiac rehabilitation participation in Medicare and Veterans Affairs populations. Circulation 2018;137:1899-1908.
16. Spitzer KA, Stefan MS, Priya A, et al. Participation in pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease among Medicare beneficiaries. Ann Am Thorac Soc 2019;16:99-106.
17. Million Hearts^® Cardiac Rehabilitation Change Package. https://millionhearts.hhs.gov/tools-protocols/action-guides/cardiac-change-package/index.html, accessed August 20, 2023.