By Serena Agusto-Cox | News & Views
A national analysis1 reported that, despite the benefits, just 19%-24% of patients referred to a cardiac rehabilitation (CR) program actually enroll and participate. One of the foundational objectives of Million Hearts® is to boost CR enrollment to 70%. Tracy Herrewig, MS, RCEP, MAACVPR, clinical exercise physiologist in Cardiovascular and Pulmonary Services at SSM Health, St. Agnes Hospital, in Fond du Lac, Wisconsin, calls the Cardiac Rehab Change Package (CRCP) “a roadmap to recovery.”
Once referred to CR, the onus is on the patient to take the next steps. Research2 has shown that for every day a patient does not sign up, the odds of them doing so decreases by 1%. Efficient enrollment into CR hinges on education and communication between patients (and their support systems) and staff, as well as between inpatient and outpatient program staff.
Educate Hospital Staff and Cardiac Patients About CR’s Value
It’s critical that everyone from providers to hospital staff fully comprehend the value, components, and processes of outpatient CR. Without this fundamental understanding, they cannot effectively communicate information that will allow patients to make informed decisions about enrollment. Staff also need to collaborate to minimize any delay from discharge to enrollment and identify solutions to potential enrollment and participation barriers.
“Patients can benefit from enrollment and participation in the CR program in a multitude of ways from the physical to the intellectual, social, emotional, and even spiritual,” says Herrewig. “CR is a comprehensive program of monitored progressive exercise, but it is much more. It encompasses educational and supportive efforts on disease management and secondary prevention of chronic disease.”
Patient and family education begins at the time of the cardiac event or procedure (or before, if it is a planned procedure) through an inpatient liaison, printed and video material and, most importantly, through conversations with the provider who recommends enrollment into the CR program. Herrewig adds, “A patient or family who understands the value of CR is more likely to enroll and actively participate in the program and thus have the best outcome possible.” The education process continues during the outpatient program, through which lifestyle changes are introduced and reinforced.
Education during outpatient CR can be provided onsite or electronically via resources created by the hospital or additional outside groups, such as the Henry Ford Hospital, the Cardiac College, the American Heart Association, and others.
Education also entails informing the hospital staff and administration about the value of CR by utilizing information from the Million Hearts Initiative and aggregate program data from the AACVPR Registry. Patient testimonials regarding the value they derived from CR play a huge role in the perception of the program within the hospital and the community. Quality improvement projects created using this data can continually move programs toward best practices.
Communication and Collaboration Uncover Enrollment Barriers to Address
Inpatient staff can use automatic referrals and detailed clinical reports in electronic medical records to communicate the medical information and specific needs of each patient to the outpatient team. They also can communicate the same information via fax or email to the local CR program. Collaboration between inpatient and outpatient staff to introduce and effectively carry out the initial referral to and enrollment in CR is critical to effective patient care.
Standardizing not only the roles and responsibilities of inpatient and outpatient CR staff, but also how a patient’s medical information is shared, can narrow the gap between hospital discharge and initial contact with an outpatient CR program, as well as boost care efficiencies. According to Herrewig, one standard of efficiency is to schedule the initial outpatient visit/evaluation prior to patient discharge from the hospital. To ensure that the visit is comprehensive and medically appropriate, patient information from the inpatient unit should be communicated to the outpatient CR program at or before the time of discharge.
During the initial visit/evaluation of patients, CR programs should identify challenges to enrollment and participation whether through conversation or a specific screening tool. Common barriers include cultural traditions, language barriers, medical complications, a reliance on public transportation or family/friends to get to appointments, family responsibilities, and copayments. In other situations, a patient may need to almost immediately return to work after an elective percutaneous coronary intervention procedure.
The outpatient CR program would benefit from recognizing these roadblocks and potentially altering their class schedule or the patient schedule so each patient can attend as many visits as possible rather than maintaining a standard schedule where many patients cannot attend at all. Other solutions include establishing a philanthropic fund to help patients who cannot afford their medical expenses or pointing patients to resources for transportation and other concerns. According to Herrewig, outpatient CR programs that identify patient barriers to enrollment and participation can seek creative solutions that ensure the best health outcomes for each patient.
Additionally, outpatient CR programs should periodically communicate to referring facilities their performance measurement data and patient outcomes. This not only can demonstrate the effectiveness of the CR program, but also strengthen its relationship with referring hospitals and facilities, generate additional referrals, boost enrollment, and improve patient outcomes after discharge.
Patients impacted by cardiovascular disease must enroll in CR programs to achieve recovery and long-term success with the help of the recommended exercises and secondary prevention strategies introduced by the CR staff. “This can only happen when the patient is educated about the purpose and value of the program and understands the efforts of all medical professionals involved who collaborate to maximize all aspects of the patient’s care,” says Herrewig. “They need to understand CR is an extension of the provider’s office, not just a fitness center, and that the best outcomes occur when the patient actively participates in all aspects of their care — including cardiac rehabilitation.”
This article is the second in a four-part series on the Million Hearts® /AACVPR Cardiac Rehab Change Package. Read the first installment, The Three S’s of Cardiac Rehab Referrals.
References:
- Andes, P.; Keteyian, S.; Wright, J.; et al. (2017). Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings, 92(2), 234-242. https://www.sciencedirect.com/science/article/abs/pii/S0025619616306486?via%3Dihub
- Fell, J.; Dale, V.; Doherty, P. (2016) Does the timing of cardiac rehabilitation impact fitness outcomes? An observational analysis, Open Heart, 3(1), e000369. https://openheart.bmj.com/content/3/1/e000369