Ross Arena|Mark A. Williams|Daniel E. Forman|Lawrence P. Cahalin|Lola Coke|Jonathan Myers|Larry F. Hamm|Penny M. Kris?Etherton|Reed Humphrey|Vera Bittner|Carl J. Lavie
Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health Settings
homecirculationvol 125 10increasing referral participation rates outpatient cardiac rehabilitation valuable role healthcare professionals inpatient home health settings free accessresearch articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessresearch articlepdfepubincreasing referral participation rates outpatient cardiac rehabilitation valuable role healthcare professionals inpatient home health settingsa science advisory american heart association ross arena phd pt faha chair mark williams phd daniel e forman md lawrence p cahalin phd pt ccs lola coke phd rn faha jonathan myers phd faha larry hamm phd penny krisetherton phd rd faha reed humphrey phd pt vera bittner md carl j lavie md behalf american heart association exercise cardiac rehabilitation prevention committee council clinical cardiology council epidemiology prevention council nutrition physical activity metabolism ross arenaross arena mark williamsmark williams daniel e formandaniel e forman lawrence p cahalinlawrence p cahalin lola cokelola coke jonathan myersjonathan myers larry hammlarry hamm penny krisethertonpenny krisetherton reed humphreyreed humphrey vera bittnervera bittner carl j laviecarl j lavie behalf american heart association exercise cardiac rehabilitation prevention committee council clinical cardiology council epidemiology prevention council nutrition physical activity metabolism originally published30 jan 2012httpsdoiorg101161cir0b013e318246b1e5circulation 201212513211329other versions articleyou viewing recent version article previous versions january 1 2012 previous version 1 introductioncardiovascular disease cvd continues leading cause morbidity mortality united states worldwide1 fact prevalence cvd rise function increased longevity mounting effects cardiac risk factors typically accumulate lifetime outpatient cardiac rehabilitation cr programs offer costeffective multidisciplinary comprehensive approach address risk factors restore individuals optimal physiological psychosocial nutritional functional status26 thus benefits cr extend well beyond cardiovascular system positively affecting individuals overall health status benefits may particularly important certain cvd cohorts elderly patients likely present greater functional limitations frailty additionally outpatient cr shown dramatically reduce morbidity mortality nearly 25 compared usual care78despite clear benefits formal supervised outpatient cr exercise training programs well strides automatic referrals9 current statistics continue demonstrate referral participation rates eligible patients remain alarmingly low1013 participation particularly poor rural areas eligible patients lower socioeconomic status limited education advanced age andor female sex1415 addition gurewich et al16 reported several factors likely responsible poor referral rates outpatient cr included degree automation assertiveness securing referrals level integration cr within hospital setting physician community relationship cr facilities capacity constraintsgiven continually poor referral participation rate outpatient cr despite increased efforts reverse trend additional actions required scientific advisory calls inpatient home healthcare teams physicians physician assistants nurse practitioners nurses physical therapists pts clinical exercise physiologists ceps registered dieticians cr team members implement coordinated effort promote outpatient cr eligible patients facilitate referral enrollment furthermore advisory recommends identifying appropriately qualified healthcare professional lead inpatient multidisciplinary team key recommendations details whereas patientcentered care presumes programs tailored suit patient preferences implicitly places onus caregiving team educate patients promote therapies best address needs given patient opportunity inpatient healthcare team increase participation rates outpatient cr appears underappreciated therefore underused moreover home health nursing pt may also potentially play valuable role bridging gap acute care outpatient cr especially patients disabled hospital discharge thus improving continuum care potentially increased referrals ultimately participation rates therefore primary goal scientific advisory better define role key healthcare professionals inpatient home health settings ultimately improve outpatient cr referrals participationdefining key professions acute care settingmultiple providers broad range expertise routinely involved inpatient care individuals suffering cardiac event similarly wide range providers routinely attend patients primary noncardiac issue management also affected underlying cardiac disease health providers opportunity work together promote outpatient cr unifying feature care profession may way provide valuable role facilitating encouraging participation outpatient cr hospital discharge essential however strong oversight someone familiar aspects inpatient cardiac care process identified inpatient cr director empowered direct inpatient cr process including responsibilities outlined key recommendations section following sections describe several key inpatient health professionals actively promote outpatient cr although number responsibilities described overlap could accomplished one several healthcare professions member inpatient cr team offers unique skill set warranting inclusion professions described subsequent sections additionally overlapping responsibilities among health professionals involved viewed positive given build redundancy system increase likelihood eligible patients receiving key education referral outpatient cr moreover consistent communication importance outpatient cr multiple health professionals likely increase perceived value lifestyle intervention given patient unifying themes involved inpatient health professions understanding importance cr optimal recoveryoutcomes patients cvd knowledge potential outpatient cr centers given patient could referred within particular geographical region development relationship outpatient cr centers make referralenrollment process efficient possiblenursingnurses inpatient setting play pivotal role educating patients value outpatient cr cardiac eventprocedure numerous settings nurses intricately involved discharge planning instances instrumental facilitating referral outpatient cr independent predictors participation outpatient cr include patient referred outpatient cr hospital patient perceiving value need cr17 predictors could easily addressed nurse inpatient hospitalization past inpatient healthcare facilities phase cr program typically conducted nurses andor allied health professionals although many traditional phase cr programs discontinued nurses still play major role providing inpatient programming however responsibility securing outpatient cr referral providing education valuable service ambiguous inpatient nurse advocate referral encourage enrollment outpatient cr important opportunity missed nurses must cognizant outpatient cr essential component recovery eligible cardiac patients encouragement education essential first steps facilitating participation valuable lifestyle intervention hospital dischargenurses assume responsibility daytoday care patient including postoperative postprocedural monitoring vital signs cardiac arrhythmias potential complications responsible administration education cardiac medications treatments 24hour contact patient nurses position recognize key teachable moments1820 discuss outpatient cr patients qualify enrollment caregivers nurses discuss reasons obtaining referral outpatient cr facilitate process components outpatient cr program pertain individual patient welldocumented benefits outpatient cr outpatient cr provides safe environment exercise attending outpatient cr builds network resources future writing group acknowledges responsibilities specific nursing profession thus accomplished appropriate healthcare providers however increased amount contact time nurses patient provides unique opportunity ongoing indepth discussion importance outpatient crboth inpatient nurses nurse case managers often plan directly participate discharge patients postcardiac event provide education monitor patient data contribute optimal discharge plan patient cases home health care warranted nurse case manager typically directly communicates home health agency provides home nursing followup needed number patients open heart surgery provided period home health nursing pt discharge therefore nurse case managers take initiative reinforce importance outpatient cr referral home health team services complete home health professionals also facilitate encourage patient set outpatient cr appointment recovery cardiac event discussed subsequent sectionsphysical therapythe assessment functional status movement key examination pt treatment prescribed patient discharge hospital based2122 fact assessment functional status inpatient setting pt 1 method many patients deemed appropriate return home spend additional time rehabilitation center2124 although perhaps widely appreciated thus used current delivery model participation inpatient pt may potential dramatically improve referral outpatient crrecent observations suggest pt instrumental providing valuable guidance inpatient setting adherence recommendations may lower risk readmission25 observation highlights role structured assessments sharing patient information inpatient setting promoting favorable patient outcomes discharge recent longitudinal data reveal outpatient cr referral participation improve type structured inpatient assessment exists patients acute cardiac event procedure1626 pt referral inpatient intervention discharge assessment provides examination patient readiness hospital discharge entry outpatient cr program automatic referral inpatient pt already place strong case made implementation system given likelihood diminished functional capacity majority cardiac patients important step inpatient setting provides robust referral base outpatient cr26 ensures cr integrated within multiple disciplines working toward common goal ie outpatient cr referral participation course inpatient pt cardiac setting must cognizant opportunity role heshe plays promoting outpatient cr participation writing group particularly members pts acknowledges proposed recommendations may represent paradigm shift current pt practice inpatient cardiac setting however paradigm shift potential dramatically affect outpatient cr referral participation positive mannerin summary pts inpatient setting potential substantially improve outpatient cr referral given established presence inpatient cardiac setting role assessing functional capacity determining discharge status placement discharge ie home subacute rehabilitation facility2125 addition primary role assessing improving functional status inpatient pt provide education importance outpatient cr participation patient inpatient pt embrace role advocate outpatient cr educating patients value participating important lifestyle intervention ensuring referral secured dischargeclinical exercise physiologistsceps frequently members multidisciplinary team cr programs27 although likely involved outpatient program role ceps inpatient team provide expertise related exercise prescriptions training physical activity recommendations patient education exercise equipment ceps working inpatient setting likely regular contact inpatients either formal educational sessions meeting oneonone inpatients thus ample opportunities communicate clinical benefits participating outpatient cr patients eligible intervention consequently ceps knowledgeable outpatient program model referral process hours operation program details may helpful patients provides valuable link inpatient experience outpatient programfrom administrative perspective cep employed outpatient cr also responsibilities affiliated inpatient program assist monitoring inpatient census help ensure eligible patients receive referral outpatient program discharge accomplished number ways including collecting paper referrals verifying referrals electronic medical record attending staff meetings appropriate inpatient units attending discharge planning meetingsregistered dietitiansgiven poor nutritional patterns large percentage patients suffering cardiac event28 medical nutrition therapy essential therapeutic component secondary prevention cvd29 habitual diet many cardiac patients falls far short meeting recommended dietary pattern secondary prevention cvd30 extensive database demonstrates efficacy dietary intervention however sustained adherence dietary advice necessary achieve treatment goals31 reported artinian et al32 scientific literature describes impressive rates initial behavior changes cardiac event frequently translated sustained behaviorsregistered dietitians rds uniquely qualified provide medical nutrition therapy cardiac patients virtue training expertise experience33 importance rds integral member medical team acknowledged adult treatment panel iii recommends rd referral considered lifestyle therapy visit29 moreover van horn et al34 recommend patients hypercholesterolemia referred rd medical nutrition therapy thus rds inpatient setting position educate patients value outpatient cr advocate referral discharge followup required sustained nutritional behavior change uniquely important inpatient rds advocate outpatient cr services thus part ensuring eligible cardiac patients referred enrolled outpatient cr rds help patients achieve longterm nutritional goals facilitate participation essential lifestyle interventionsphysiciansthe fundamental design inpatient care cardiac patient entails coordination physician abovedescribed interdisciplinary team physicians involved care cardiac patients may come numerous disciplines surgeons interventionalists primary cardiologists primary care physicians hospitalists etc differing perspectives priorities however physicians regardless background training share common goal promoting outpatient cr eligible patients although daytoday issues addressed collaborative organization physician distinctive tasks heshe plays unique role facilitating patient intakes individual treatment planning performing patient assessments evaluating medical safety likewise physicians role perspective vital respect policies procedures physicians must reinforce value outpatient cr ensure referral eligible cardiac patients smith et al35 previously demonstrated physicianendorsed automated outpatient cr referral system results higher rates intake enrollment conversely grace et al36 demonstrated physician uncertainty member healthcare team responsible securing outpatient cr referral negatively affects eventual enrollment therefore inpatient physicians ensure outpatient cr referral system exists institution identify members healthcare team responsible securing referral express strong support process physicians also express strong support outpatient cr aforementioned health professionals involved care cardiac patients ensure members inpatient team discussendorse outpatient cr respective patient interactions moreover interactions patients families caregivers physicians convey importance outpatient cr recovery strongly encourage participation shown improve enrollment9 finally physician assistants nurse practitioners often work closely physicians adopt principles recommendations described sectionthe continuum care home health nursing pt immediate postdischarge periodaccording recent estimates roughly 76 million people united states receive communitybased care37 significant proportion receiving medical therapeutic interventions home moreover majority home health patients 65 years age number expected increase population ages unexpectedly frequent diagnoses distributed across clients endocrine circulatory disorders nearly one third home health patients present diabetes mellitus andor heart disease 40 hypertension two thirds diseases circulatory system38poor referral participation rates outpatient cr programs well documented patients discharged inpatient setting15 presuming low referral participation rates outpatient cr programs applied home health patients likely low percentage population managed home provided optimal interventions help achieve goals preserving functional independence maximizing secondary prevention benefits outpatient cr well established39 solidifying continuity care home health institution providing outpatient cr vitally important reaching everexpanding group patients need lifestyle modificationbecause home health often provided nurses pts focus population potential avenues exist expand expertise practitioners effort lay foundation eventual participation outpatient cr educational exercise training perspective home setting patients would benefit risk factor reduction education thus woven home health treatment plan initial exercise training program ecg monitoring via portable monitoring units telecommunication feasible use dictated clinical status individual patient even effective monitoring vital signs symptoms tolerance exercise combined fundamental principles exercise prescription serve majority nurses pts well overall management home health patient chronic disease eventually amenable outpatient cr noted patients treated home become appropriate candidates outpatient cr clinical judgment nurse andor pt assist physician determining correct therapeutic approach however referral participation outpatient cr goal eligible patients longer homeboundfrequently time gap acute care discharge initiation outpatient cr occurs creating break continuum care patients receiving home health care nurse andor pt reiterate components benefits safety outpatient cr patient ideally taught inpatient healthcare team assist facilitating appointment appropriate one yet made maintaining continuum care important concept improve patient perception outpatient cr choice expectation complete recovery moreover many barriers contribute patients attend cr including lack access transportation issues perceived inconvenience caring spouse others home financial need return work15174041 home health nurse andor pt often provide resources andor strategies may help patient overcome barriers finally although roles responsibilities home health nurse pt may differ unifying themes described previously inpatient health professionals certainly apply setting wella number established outpatient cr programs incorporate home health range services42 training support home health nurses pts effectively manage patients appropriate cr strategies readily provided outpatient cr program staff collaboration also likely facilitate transition home health care outpatient cr enrollment correct juncture patients recoverykey recommendationsthe process identifying key personnel direct implement early inpatient cr educate outpatient cr subsequently facilitate patient entry outpatient cr program dependent resources inpatient setting including administrative structure available personnel philosophical approach various economic regulatory considerations ideally smooth transition inpatient outpatient cr programming likely dependent initial administrative designations responsibilities table provides recommendations inpatient cr programs would facilitate referral participation outpatient crtable recommendations inpatient health professionals improve referral outpatient cardiac rehabilitationformulation multidisciplinary inpatient cr program assess prepare patients discharge home eventual participation outpatient cr share relevant patient status progress information inpatient cr relevant inpatient healthcare professionals help identify patients ready initiation exercise participation outpatient cr patients risk functional decline depression anxiety psychological social problems may hinder acute subacute longterm rehabilitation progress consider referral home health therapy bridge outpatient cr patientsinitiation automatic referral appropriate inpatient health professionals assess readiness patients cardiac event discharge home participation outpatient cr program via functional assessment functional performance measure ie 6mwt tug examine functional status directly enable prescription assistive devices exercise indicated performance submaximal exercise test via lowlevel treadmill cycle ergometry exercise appropriate patients use generic ie sf12 sf36 andor specific ie mlwhfq duke activity scale functional status questionnaires examine perceived functional status assessment selfefficacy ie cardiac selfefficacy scale nutritional assessmentdevelopment examination evidencebased multidisciplinary models discharge planning focus educating inpatient health professionals methods implement items educating inpatient health professionals interpretation items developing different methods improve referral outpatient cr acute subacute longterm rehabilitation hospitalization complete increasing referrals participation outpatient cr consider implementing quality indicators objectively track outpatient cr referral performancecr indicates cardiac rehabilitation 6mwt 6minute walk test tug timed upandgo sf12 medical outcomes short form12 sf36 medical outcomes short form36 mlwhfq minnesota living heart failure questionnairethe functional assessment submaximal exercise test inpatient cr program use methods outlined american association cardiovascular pulmonary rehabilitation cardiac rehabilitation guidelines including monitoring symptoms vital signs ecg appropriate patients well american association cardiovascular pulmonary rehabilitationamerican college cardiologyamerican heart association performance measures cardiac rehabilitation101127the american heart association american college cardiology previously described patients may appropriate lowlevel exercise testing394344at outset planning process important develop inpatient cr structure led individual inpatient cr director possesses strong background cvd prevention rehabilitation including exercise training cvd risk factor behavioral modification program development interpersonal skills necessary direct personnel various health care disciplines nursing pt cep dietary also essential addition inpatient cr director must enthusiastic advocate outpatient cr interactions facility administrators healthcare professionals involved number crrelated publications inpatient healthcare team thoroughly review perhaps two important documents healthcare team members understand completely particularly inpatient cr director aacvpraccfaha 2010 update performance measures cardiac rehabilitation referral cardiac rehabilitationsecondary prevention services report american association cardiovascular pulmonary rehabilitation american college cardiology foundationamerican heart association task force performance measures writing committee develop clinical performance measures cardiac rehabilitation11 earlier 2007 publication10 publications advocate use performance measure assess outpatient cr referral patterns inpatient setting practice current writing group strongly endorses publications detail process developing automatic referral outpatient cr also strongly endorsed current writing group45 finally publications invaluable developing policies procedures inpatient outpatient cr include american hea