By Serena Agusto-Cox | News & Views
Cardiovascular rehabilitation (CR) is an essential core of recovery for cardiovascular patients. To be impactful and effective, patients must be referred to CR by their surgeons or providers. “Successful CR referral programs can be modeled to be S3 — socialized, standardized, and synthesized,” according to Ana Mola, PhD, RN, ANP-BC, MAACVPR, clinical assistant professor of Rehabilitation Medicine at NYU School of Medicine and AACVPR past president. The Cardiac Rehab Change Package, developed in partnership with Million Hearts®, outlines a number of ways that hospitals and providers can ramp up S3 CR referrals for the wellness of their patients.
Socialize CR
Within the medical and hospital system, CR needs to be socialized among staff, patients, and caregivers. Through scripting, or a common language, providers and the care team can educate patients about CR’s benefits and why a referral can make a difference to the wellness of the patient. Nurses and the interdisciplinary team can be educated in this common language to ensure patients and caregivers are clear as to why CR referrals are made and that it is an essential part of the patient's discharge care. Included in the package are examples of this kind of scripting, including one from the KITE-Toronto Rehabilitation Institute, University Health Network.
“A motivational letter to patients can go a long way in providing them and their caregivers with the information they need to enroll in CR after referral,” according to Mola. Similarly, CR can offer providers the impetus for referring patients to CR through education on its benefits for patients and as a means of reducing readmissions.
All forms, brochures, and information packets provided to patients and their families should be communicated using the same scripting. This includes print and electronic communication, as well as reminders issued to nurses and providers who have contact with the patients before discharge, so they can inform them about CR and their referrals. “Establishing an auto enrollment program for CR is the easy part,” says Mola. “Getting patients to follow through is the challenge.”
Standardize CR
Electronic medical records (EMRs) should be updated to remind providers and the interdisciplinary team to order CR referrals when patients’ records reflect specific diagnoses or surgeries. Although getting IT on board with these changes will require buy-in from managers and executives of the system, nurses and providers can add information to the EMRs about CR referrals. This will happen naturally once providers, nurses, and staff are socialized and trained on how to broach the CR referral with patients. Systemwide reminders normalize the need for cardiovascular patients to be referred to CR.
Reminders in EMRs are just one step in the standardization process. The larger care team, including each hospital’s care managers (CMs), cardiologists, nurses, and CR staff, need to work together to create a discharge process that drives patients to the recovery care they need. CMs will often check in on patients after discharge from the hospital to ensure they are getting appropriate care, and part of that process should be to ask about CR enrollment and the benefits of CR programs. “Additionally, some health insurers have lines of business that include managed care products that execute health services of Medicare and Medicaid beneficiaries and have CMs who should be involved in the CR referral process,” Mola adds.
Policies, processes (including CR referral process maps like that from Lake Regional Health System), and paperwork should be standardized and have the same information about CR’s benefits and how to enroll, even if there is an auto-enrollment program in place. Everyone is practicing CR referrals with the same script and engaging in enrollment referrals with the same messaging for every channel a patient touches. “This is how hospitals and CR can bridge the care continuum,” says Mola.
Synthesize CR
Capturing patient population data for all CR-eligible diagnoses is part of the synthesizing process of CR referrals, and this data can be broken down into how many patients were referred to CR (see AACVPR’s Introduction to Cardiac Rehabilitation Performance Measures and the Penn Medicine Dashboard). According to Mola, “This is an important part of the process in socializing and standardizing CR referrals, because you can identify which cardiologists, departments, or staff are under-referring and use focus groups to uncover why they didn’t refer more patients to CR.”
Additionally, hospitals can use focus groups to reach out to patients who received CR referrals and didn’t enroll to determine any barriers to their discharge care. “They could have issues with CR times due to inflexible work schedules, an inability to pay co-payments, or transportation issues,” she explains. “Some of these challenges can be addressed with CMs and health plans or even additional resources that help patients with transportation to medical appointments or other issues.”
“It is critical for the gap between CR referrals and enrollment to be addressed in a short period of time,” says Mola. “Otherwise, patients may not enroll and get the care they need.”
Mola points out that systemwide change can be daunting, but she says that to accomplish worthwhile change, even baby steps matter. For instance, hospitals could deploy a pilot program in one cardiac department to socialize and standardize the CR referral process and then synthesize and update the process to make it standard and applicable throughout the system.
“The Cardiac Rehab Change Package is priceless because it is diverse enough to meet programs where they are,” she explains. It contains resources, process maps, fact sheets, examples, and templates that small to large programs can use to create change in their own backyards without being overwhelmed.