By Serena Agusto-Cox | News & Views
Cardiac rehabilitation (CR) programs are only as successful as their participants. The challenge for program leaders is to ensure that referred patients not only enroll in the program but also stick to it. Kate Traynor, RN, MS, FAACVPR, retired director of the Cardiovascular Disease Prevention Center at Massachusetts General Hospital, says the Cardiac Rehab Change Package (CRCP), developed in partnership with Million Hearts®, can guide CR programs through avenues to improve patient adherence.
U.S. Centers for Medicare and Medicaid Services (CMS) guidelines allow CR coverage for eligible patients per qualifying cardiac event and, under those guidelines, patients have up to 36 weeks to complete the program. To be consistent, most CR programs follow those same CMS guidelines for all enrolled patients, according to Traynor. These programs must complete an individual treatment plan (ITP) every 30 days for program participants, even if they don’t attend the program sessions regularly and do not demonstrate any progress toward the goals in the ITP. Program staff must keep accurate records because there is a chance that individuals who are inconsistent with program attendance could return within the 36-week period to resume their CR program.
Recapture CR Enrollees Within 36 Weeks
“Non-completers, who are also sometimes referred to as dropouts, are the patients who CR program staff need to capture through education and understanding,” says Traynor. “What are the patient factors or reasons that these patients are not completing the CR program, and how can programs keep them engaged through the entire process? How can we see them through to completion?”
Each CR program needs a plan in place for how they will address patients who stop attending regularly. Traynor says a clear communication plan with the patient, their referring provider, and healthcare team is essential. Ideally, program staff should reach out to patients about their absence and, as one option, can employ automated reminders via mobile technology. Determining challenges or barriers patients may face in attending future sessions is important to identify and address in order to improve adherence. Updating the referring provider on each patient’s progress can be another lever to pull should a patient stop attending sessions. These efforts by CR staff can assist them to determine which patients have decided not to continue participation and why.
To re-engage CR patients, programs need to create and consistently engage in outreach. “You need to express that you’d love for them to continue with the program and outline some strategies that could re-engage them and keep them active,” explains Traynor. “Patients that complete the CR program, or at least 12 visits, do better than patients who don’t. The program is not just about exercise; rather it’s also inclusive of counseling, nutrition, weight management, smoking cessation, and the psychosocial support that CR patients need after a cardiac event to stay healthy.”
According to the latest studies, anywhere from 24%-50% of patients don't complete programs1, says Traynor. “You don't want to lose those patients once you've evaluated and enrolled them,” she says. “You’ve built the referral and enrollment processes, like in Field of Dreams — “If you build it, [they] will come” — and yet another equally important consideration is will they stay, or adhere, and complete the program.”
The $64,000 Question
Once the patient walks through the CR program’s doors, Traynor says the $64,000 question becomes how do programs improve the graduation or adherence rate. She explains that CR staff must first determine if process or organizational factors are negatively influencing patient adherence. Additionally, they need to examine patient variables that could be hindering participation.
If patient variables are the obstacle, shifts or modifications in the CR program’s processes may address those issues. To understand these variables, staff need to conduct assessments to pinpoint which groups of patients are most at risk of not completing the program.
“You have to look at your data,” explains Traynor. “If you have 100 patients enrolled and just 75 complete the program, 25% of enrollees are not adhering. Programs need to look at the characteristics of non-completers and compare them to the program’s graduates. Are the non-completers mostly smokers? Are there more women in the group? Are most of the non-completers non-English speakers?”
According to Traynor, “The advantage of knowing that information and understanding your patient population is that you can step in earlier during enrollment.” For instance, if you have patients who are smokers, she says the program could engage tobacco treatment specialists or additional programs to help patients at the start of their CR journey.
“A simple approach such as the use of the CAGE (cut down, annoyed, guilty and eyeopener) Questionnaire to evaluate a given patient’s risk for alcohol abuse is another tool that CR programs can consider using to identify CR participants who may need help in this area. Patients who answer, ‘yes’ to two out of the four questions are often at risk of non-adherence,” she explains.
“Non-English-speaking patients can be particularly challenging, especially if it can be difficult to schedule medical interpreters during CR session times,” points out Traynor. “It is less than ideal to rely on family members to act as interpreters because they may not understand the medical terms or there may be cultural boundaries that prevent them from sharing information candidly.”
Knowing these variables ahead of time can aid CR programs in understanding their enrollees and providing additional support to those patients who may need it to retain them through to program completion. Staff also need to measure their success by evaluating their program data and employing one of the many tools in the CRCP to determine which changes lead to a drop in non-completion rates. “‘The act, plan, study, do’ quality improvement method described in the CR Change Package is extremely helpful in this regard. It is a ‘cyclical’ process such that you can start at any point in the cycle when attempting to address barriers to CR program adherence by participants,” says Traynor.
Get Creative With CR Patient Solutions
With the data in hand, CR programs can choose one group of non-adhering patients to address. “Don’t pick them all. Pick one that seems to be a high-frequency issue,” advises Traynor. “You look at the resources you have available to address the patient variable and what resources may be available in the community. Pull those resources in early and measure the results. Did non-completion rates for that group decline? If not, determine what other options are available to address those concerns.”
Non-adherence rates are a universal challenge for every CR program, but each program must assess how they can improve their program’s processes or structures to address their challenges. For instance, if medical interpreter services are hard to schedule, consider using devices or other technologies that can translate information on the spot for patients. These devices allow for two-way communication between patients and staff.
Another resource for CR staff to assist with adherence challenges is hospital quality improvement teams. “Those teams may not solve the problem for the CR program, but they can provide helpful guidance to problem-solve challenges with non-completion rates,” Traynor explains. “Astute managers and clinicians are in the trenches with CR patients, and they can see the program’s data. Together they can cohesively study and create a plan of action to address non-adherence.”
Effective communication is key in CR. For patients who miss two or more sessions, re-engaging them may be a simple phone call away. “Just reach out by phone and tell them they were missed by the staff and their peers. Ask about how things have been going, how they have been feeling, and ask about when they are likely to return or what may be in the way of that,” she advises.
If a patient works 9 a.m. to 5 p.m. and the CR sessions are offered during that same time, the program could consider altering the program schedule such that patients don’t have to choose one over the other. Or it could begin offering a combination of in-person and remote classes. Traynor says, “Providing class schedules up front, asking about potential conflicts, and offering different dates and times at the onset can set patients up for successful completion.”
“Sometimes you have to think a little bit creatively on the back end to keep CR patients engaged,” she explains. If finances are a potential barrier, CR staff could consider reaching out to insurance companies to reduce co-payments for patients or create a philanthropic fund (refer to the CRCP to explore the Henry Ford Health System approach) to assist with patients’ out-of-pocket expenses.
Other options for improving patient engagement include providing patients with compassion, empathy, and the human touch; providing additional education about the benefits of CR; increasing social engagement between patients in the same cohort (i.e., placing chatty patients near soft-spoken or newer participants); offering patients tips on how to succeed in CR; and ensuring they receive the education they need to make a healthy transition out of CR.
Finally, Traynor says CR programs should make graduating from the program a celebration. “Make a room-wide announcement when someone completes the program and provide a certificate of completion and a t-shirt or other swag. Make it something to celebrate and be proud of because it is,” she says. “Those celebratory moments can serve as a motivator for other patients to complete their CR journeys.”
This article is the third in a four-part series on the Million Hearts® /AACVPR Cardiac Rehab Change Package. Read the first two installments: The Three S’s of Cardiac Rehab Referrals and Roadmap to Recovery: Boosting CR Enrollment With Education, Communication, and Collaborative Participation.
References:
- Aharon, K.; Keteyian, S.; Gershfeld-Litvin, A.; et al. (2022). Improving cardiac rehabilitation patient adherence via personalized interventions. PLoS One, 17(8): e0273815. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9423647/