THE FUNDAMENTALS OF
SETTING UP A CARDIAC
REHABILITATION PROGRAM.
“ Do’s and Dont’s “
ANTONIO S. SIBULO Jr.MD,FPCC,FAsCC,FACC
St.Luke’s Heart Institute
What is Cardiac Rehabilitation?
Cardiac rehabilitation is a medically
supervised program designed to
optimize a cardiac patient’s physical,
psychological, and social function.
In addition, it aims to stabilize, slow or
even reverse the progression of the
underlying atherosclerotic processes,
thereby reducing death and disability.
Why Run a Cardiac
Rehabilitation Program?
 It is recognized as an integral component of the
continuum of care for patients with cardiovascular
disease. Its application is a Class I Recommendation
in most contemporary cardiovascular clinical
practice guidelines.
J Am Coll Cardiol 2008;51:1619–31
 Participating in a cardiac rehabilitation (CR)program
after a cardiac event yields well-established benefits
in reducing cardiac and non-cardiac mortality as well
as reducing morbidity and cardiac risk factors .
Taylor AS et.al Am J med 2004;116:682-92
Why Run a Cardiac
Rehabilitation Program?
Because of this mounting evidence, a number of
health care organizations have endorsed the use
of CR services in persons with CVD by including
provisions for CR in their practice guidelines
and position papers.
AACPVR/ACC/AHA 2007 Performance measures on Cardiac Rehabilitation for
Referral to and Delivery of cardiac Rehabilitation/Secondary Prevention
Services
What are the benefits of Cardiac
Rehabilitation?
The benefit is thought to be mediated by several
factors, including:
 Benefits of exercise training
 Psychological benefits of group support and
counseling
 Improved adherence to preventive therapies
 Improved control of cardiovascular risk factors.
What are the demonstrated
benefits of Cardiac Rehabilitation?
 A 20-30% reduction in all-cause mortality rates
Decreases mortality up to 5 years post participation
Reduced symptoms (angina, dyspnea, fatigue)
Reduction in nonfatal recurrent myocardial over
median follow-up of 12 months
Improves adherence with preventive medications
Increased exercise performance
Improved lipid panel (total cholesterol, HDL, LDL ,
and triglycerides)
What are the demonstrated
benefits of Cardiac Rehabilitation?
 Increased knowledge about cardiac disease and its
management
Enhanced ability to perform activities of daily living
Improved health-related quality of life
Improved psychosocial symptoms (reversal of anxiety
and depression, increased self-efficacy)
 Reduced hospitalizations and use of medical resource
Return to work or leisure activities
Evidence Supporting Cardiac
Rehabilitation
Cardiac rehabilitation is now a Class I Indication in
clinical guidelines for:
Myocardial infarction (MI)
Percutaneous Coronary Intervention (PCI)
Coronary artery bypass grafting (CABG)
Angina
Heart failure
Valvular heart disease
Peripheral arterial disease (PAD)
Group of Patients who will
Benefit from CaRe
Patients with a history of:
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Myocardial infarction (heart attack)
Coronary artery bypass graft surgery (CABG)
Current stable angina pectoris
Heart valve repair or replacement
Percutaneous transluminal coronary angioplasty
(PTCA)/ or coronary stenting
Heart or heart-lung transplant
Heart Failure and those with ventricular assist
devices
Coronary artery disease equivalents such as
diabetes or peripheral artery disease
Patients with diabetes
Peripheral arterial disease
Components of Cardiac
Rehabilitation (4)
1. Physician prescribed exercise
Exercise training and other
therapeutic exercise including
aerobic and strength training.
An Individualized Treatment Plan (ITP) is a required
element that describes the individual’s diagnosis, the type,
amount, frequency and duration of the items and services
under the plan and the goals set for the individual under the
plan. The plan is written, established, reviewed, and signed
by a physician every 30 days.
Components of Cardiac
Rehabilitation
2. Cardiac risk factor modification
 Includes education, counseling, and behavioral intervention;
related to the individual’s care and tailored to the individual’s
needs.
 It may include a combination of one or more of the following.
Physical Activity
Nutrition
Lipid management
Blood pressure management
Smoking cessation
Weight management
Diabetes management
Psychosocial management
Components of Cardiac
Rehabilitation
3. Psychosocial Assessment
Evaluation of the individual’s mental and emotional
functioning as it relates to the individual’s
rehabilitation or cardiac condition.
4. Outcomes Assessment
Evaluation of the patient’s progress as it relates to the
individual’s rehabilitation goals and program.
Education, counselling and behavioral
interventions
CONSIDER ORGANISATIONAL ASPECTS
LOCATION
Gym/Fitness Center
EQUIPMENT
Bicycle/Arm Ergometer
Treadmill
Stepper
Rowing machine
Free weights
12 Lead ECG machine
Cardiac defibrillator/AED
Organizational Issues
Cost savings and Cost effectiveness
In setting up a care program- Do’s
Promote your program through Publicity and Advertising
 In your efforts, target your community at large. Be sure to include
hospital administrators, physicians, coworkers, and current patients.
 Advertise your program through your in-house newsletters and
bulletins.
 Arrange for interviews on radio or local news magazine shows to
publicize your hospital’s program. Provide specific information on
heart disease prevention and rehabilitation.
 Sponsor an educational program or seminar for health
professionals. Make your special events fun and educational. Offer
risk factor assessments, smoking cessation clinics, heart-healthy
cooking classes, etc.
In setting up a care program- Do’s
Individualize Evaluation and Goal development for every
patient
 The Staff should be committed to treating each
patient as a unique individual with special needs and
concerns.
 Ensure that systems are present to obtain the
clinical informations so that the CaRe team can
develop an appropriate patient-centered treatment
plan that prioritize goals and outlines intervention
strategies for exercise training, tactics to reduce
cardiovascular disease risk and a follow-up plan that
reflects progress towards goals.
In setting up a care program- Do’s
Individualize Evaluation and Goal development for
every patient
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Results of recent cardiac tests including TET,ECG,2DE
Status of cardiopulmonary ,orthopedic and
neuromuscular system, cognitive function
Detailed review of CV risk factors
Complete list of medications
Patient specific symptoms of angina or its equivalents
Comorbid conditions with attention to their impact
on exercise, adherence and disease progression
Pertinent psychosocial and occupational history
In setting up a care program- Do’s
Device Strategies to improve Referrals
 Clinicians should consider instituting processes that
encourage referral of appropriate patients to CARE. In
addition, it is important that referring healthcare
practitioners and CARE teams communicate in ways
that promote patient participation
Implementation of standing referral orders to CARE
based on eligible diagnoses supported by clinician
guidelines. These “systematic” strategies are
implemented manually or may be autumativally using
discharge order sets in medical records.
In setting up a care program- Do’s
Device Strategies to improve Referrals
 “liaison” strategies- in which a healthcare provider
or peer mentor speaks to the patient at the bedside
about CARE and facilitates referral while
permitting discussion of the nature and merits of
such programs and potential barriers to
participation.
Dissemination of patient education materials or
motivational letters both designed to augment
CARE utilization.
Grace SL et al. Referral to and discharge from cardiac rehabilitation: Key
informant views on continuity of care. Presented at the University Health Network
Annual Research Day. Toronto, ON:2003.
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In setting up a care program- Do’s
Device Strategies to improve Referrals
“Automatic“- in which the patient would be sent a letter detailing the
clinic appointment
Liaison- when a healthcare professional would explain the benefits
of the program to the patient while they were still in the hospital
Combination of the two previous approaches.
Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation
referral strategies on utilization rates. Arch Intern Med 2011; 171:235-241.
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In setting up a care program - Do’s
Address the Common Barriers to Cardiac Rehab
Participation
• Age- younger patients more likely to participate
• Gender difference- female patient less likely to
participate
• Financial
• Lack of Patient Motivation
• Patient work and time conflicts
• Lack of Physician support and referral
• Distance and transportation
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In setting up a care program - Do’s
Incorporate CARE Program to packages of CV care to
ensure Utilization
• The program director should address issues pertaining
to reimbursement of services
• Currently, where issues regarding insurance coverage
and copayment of services by the patient may hinder
referral to cardiac rehab, efforts should be made to
incorporate these programs in CV care payment
packages to ensure its utilization.
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In setting up a care program - Do’s
•
Incorporate CaRe Program to packages of CV care to ensure
Utilization
Phase of
Cardiac Rehab
Number of inclusive
sessions
(8,12,24,36..)
Phase I
PhaseII
Phase III
Phase IV
Items inluded in
package:
Gross
amount
Discounted
Amount
Cardiac rehab service
Stress Test
Doctor's Fee
Diet Counselling fee
Telemetry
monitoring
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In setting up a care program - Do’s
Promote Physician and Patient Education with emphasis on
Lifestyle changes as an intergral part of secondary prevention
strategies
Rehabilitation phase includes patient education
sessions regarding lifestyle change, diet and
detrimental habits, such as smoking.
Apply specific educational strategies to achieve
behavioral change that will address cardiac risk
factors and optimize compliance to medication and
exercise training.
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In setting up a care program - Don'ts
Don't forget the following:
Close interaction with the patient's primary care provider,
cardiologist and cardiovascular surgeon who cares for the the
patient's overall cardiovascular health.
 Identify high risk patients for closer monitoring and those who
need further cardiac work-up
Monitor patient progress toward achieving goals and ensure that
patient and program outcomes are consistent with current clinical
practice guidelines
Make CARE sessions interesting and promote patient interaction
to encourage group support
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Exercise Training
Outline
Measures of
Performance of Care Indices
Why a need for Performance
Measures
• Designed as a mechanism to rapidly translate
strong clinical evidence into practice
• Provide incentive for rehabilitation referral
• Set standards of care
Measures of Performance of Care
Indices
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Patient assessment
Nutritional counseling
Weight management
Blood pressure management
Lipid management
Measures of Performance of Care
Indices
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Diabetes management
Tobacco cessation
Psychosocial management
Physical activity counseling
Exercise training
Use of preventive medications
Data collection for CARE
Thank You! Let’s all Live a
Healthy Life!!