Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health Settings
2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 10 Linguagem: Inglês
10.1161/cir.0b013e318246b1e5
ISSN1524-4539
AutoresRoss Arena, Mark A. Williams, Daniel E. Forman, Lawrence P. Cahalin, Lola A. Coke, Jonathan Myers, Larry F. Hamm, Penny M. Kris‐Etherton, Reed Humphrey, Vera Bittner, Carl J. Lavie,
Tópico(s)Stroke Rehabilitation and Recovery
ResumoHomeCirculationVol. 125, No. 10Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health Settings Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBIncreasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health SettingsA Science Advisory From the 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 Kris-Etherton, PhD, RD, FAHA, Reed Humphrey, PhD, PT, Vera Bittner, MD, Carl J. Lavie, MD and on behalf of the American Heart Association Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity and 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 Kris-EthertonPenny Kris-Etherton , Reed HumphreyReed Humphrey , Vera BittnerVera Bittner , Carl J. LavieCarl J. Lavie and on behalf of the American Heart Association Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity and Metabolism Originally published30 Jan 2012https://doi.org/10.1161/CIR.0b013e318246b1e5Circulation. 2012;125:1321–1329Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 IntroductionCardiovascular disease (CVD) continues to be the leading cause of morbidity and mortality in the United States and worldwide.1 In fact, the prevalence of CVD is on the rise as a function of increased longevity and the mounting effects of cardiac risk factors that typically accumulate over a lifetime. Outpatient cardiac rehabilitation (CR) programs offer a cost-effective, multidisciplinary, comprehensive approach to address these risk factors and to restore individuals to their optimal physiological, psychosocial, nutritional, and functional status.2–6 Thus, the benefits of CR extend well beyond the cardiovascular system, positively affecting an individual's overall health status. These benefits may be particularly important to certain CVD cohorts such as elderly patients who are more likely to present with greater functional limitations and frailty. Additionally, outpatient CR has been shown to dramatically reduce morbidity and mortality by nearly 25% compared with usual care.7,8Despite the clear benefits of formal, supervised outpatient CR and exercise training programs, as well as strides in automatic referrals,9 current statistics continue to demonstrate that referral and participation rates of eligible patients remain alarmingly low,10–13 with participation particularly poor in rural areas and in eligible patients who have lower socioeconomic status, limited education, advanced age, and/or female sex.14,15 In addition, Gurewich et al16 reported several factors that are likely responsible for the poor referral rates to outpatient CR, which included "the degree of automation and assertiveness in securing referrals, the level of integration of CR within the hospital setting and physician community, the relationship to other CR facilities, and capacity constraints."Given the continually poor referral and participation rate in outpatient CR despite increased efforts to reverse this trend, additional actions are required. This scientific advisory calls on the inpatient and home healthcare teams (physicians, physician assistants, nurse practitioners, nurses, physical therapists [PTs], clinical exercise physiologists [CEPs], registered dieticians, and CR team members) to implement a coordinated effort to promote outpatient CR to eligible patients and to facilitate referral and enrollment. Furthermore, this advisory recommends identifying an appropriately qualified healthcare professional to lead the inpatient multidisciplinary team (Key Recommendations for further details). Whereas patient-centered care presumes that programs can and should be tailored to suit patient preferences, it implicitly places an onus on the care-giving team to educate patients and to promote therapies that will best address needs of a given patient. The opportunity for the inpatient healthcare team to increase participation rates in outpatient CR appears to be underappreciated and therefore underused. Moreover, home health nursing and PT may also potentially play a valuable role in bridging the gap between acute care and outpatient CR, especially for patients who are more disabled after hospital discharge, thus improving the continuum of care and potentially increased referrals and ultimately participation rates. Therefore, a primary goal of this scientific advisory is to better define the role of key healthcare professionals in both the inpatient and home health settings to ultimately improve outpatient CR referrals and participation.Defining Key Professions in the Acute Care SettingMultiple providers, with a broad range of expertise, are routinely involved in the inpatient care of individuals suffering a cardiac event. Similarly, a wide range of providers routinely attend to patients with a primary noncardiac issue but with management also affected by underlying cardiac disease. These health providers have the opportunity to work together to promote outpatient CR as a unifying feature of care. Each profession may, in its own way, provide a valuable role in facilitating and encouraging participation in outpatient CR after hospital discharge. It is essential, however, that strong oversight by someone familiar with all aspects of the inpatient cardiac care process be identified ("inpatient CR director") and empowered to direct the inpatient CR process, including those responsibilities outlined in the Key Recommendations section. The following sections describe several key inpatient health professionals who can and should actively promote outpatient CR. Although a number of the responsibilities described overlap and could be accomplished by one of several healthcare professions, each member of the inpatient CR team offers a unique skill set, warranting inclusion of all professions described in subsequent sections. Additionally, overlapping responsibilities among the health professionals involved should be viewed as positive, given that it will build redundancy into the system and increase the likelihood of eligible patients receiving key education and a referral to outpatient CR. Moreover, consistent communication of the importance of outpatient CR from multiple health professionals is likely to increase the perceived value of this lifestyle intervention by a given patient. Unifying themes for all involved inpatient health professions are an understanding of the importance of CR to optimal recovery/outcomes in patients with CVD, a knowledge of all potential outpatient CR centers to which a given patient could be referred within a particular geographical region, and development of a relationship with these outpatient CR centers to make the referral/enrollment process as efficient as possible.NursingNurses in the inpatient setting can play a pivotal role in educating patients about the value of outpatient CR after a cardiac event/procedure. In numerous settings, nurses are intricately involved in discharge planning and, in these instances, can be instrumental in facilitating a referral to outpatient CR. Independent predictors of participation in outpatient CR include the patient being referred to outpatient CR while in the hospital and the patient perceiving the value and need for CR.17 Both of these predictors could easily be addressed by the nurse during inpatient hospitalization. In the past, most inpatient healthcare facilities have had a phase I CR program, typically conducted by nurses and/or other allied health professionals. Although many traditional phase I CR programs have been discontinued, nurses still play a major role in providing inpatient programming. However, the responsibility of securing the outpatient CR referral or providing education on this valuable service can be ambiguous. If the inpatient nurse does not advocate for referral and encourage enrollment in outpatient CR, an important opportunity is missed. Nurses must be cognizant that outpatient CR is an essential component of the recovery of all eligible cardiac patients and that their encouragement and education are essential first steps to facilitating participation in this valuable lifestyle intervention after hospital discharge.Nurses assume responsibility for the day-to-day care of the patient, including postoperative or postprocedural monitoring of vital signs, cardiac arrhythmias, and potential complications, and are responsible for the administration of and education about cardiac medications and treatments. During this 24-hour contact with the patient, nurses are in a position to recognize key "teachable moments"18–20 and to discuss outpatient CR with patients who qualify for enrollment and their caregivers. Nurses should discuss the reasons for obtaining a referral for outpatient CR and facilitate the process, the components of an outpatient CR program and how they pertain to the individual patient, the well-documented benefits of outpatient CR, how outpatient CR provides a safe environment for exercise, and how attending outpatient CR builds a network of resources for the future. The writing group acknowledges that these responsibilities are not specific to the nursing profession and thus can be accomplished by other appropriate healthcare providers. However, the increased amount of contact time between the nurses and the patient provides a unique opportunity to have an ongoing, in-depth discussion of the importance of outpatient CR.Both inpatient nurses and nurse case managers often plan and directly participate in the discharge of the patient's postcardiac event. They provide education, monitor patient data, and contribute to the optimal discharge plan for the patient. In cases when home health care is warranted, the nurse case manager typically directly communicates with the home health agency that provides home nursing follow-up when needed. A number of patients who have had open heart surgery are provided a period of home health nursing and PT on discharge. Therefore, nurse case managers should take the initiative to reinforce the importance of outpatient CR referral to the home health team once those services are complete. Home health professionals should also facilitate and encourage the patient to set up an outpatient CR appointment after recovery from the cardiac event, as is discussed in subsequent sections.Physical TherapyThe assessment of functional status and movement is a key examination from which PT treatment is prescribed and on which patient discharge from the hospital is based.21,22 In fact, the assessment of functional status in the inpatient setting by PT is 1 method by which many patients are deemed appropriate to return home or to spend additional time at a rehabilitation center.21–24 Although perhaps not widely appreciated and thus used in the current delivery model, participation in inpatient PT may have the potential to dramatically improve referral to outpatient CR.Recent observations suggest that PT can be instrumental in providing valuable guidance in the inpatient setting and that adherence to recommendations may lower the risk of readmission.25 This observation highlights the role that structured assessments and sharing of patient information in the inpatient setting have in promoting favorable patient outcomes after discharge. Recent longitudinal data reveal that outpatient CR referral and participation improve when this type of structured inpatient assessment exists for patients with an acute cardiac event or procedure.16,26 PT referral for inpatient intervention and discharge assessment provides an examination of patient readiness for hospital discharge and entry into an outpatient CR program. If an automatic referral for inpatient PT is not already in place, a strong case can be made for the implementation of such a system given the likelihood of a diminished functional capacity in the majority of cardiac patients. This important step in the inpatient setting provides a robust referral base for outpatient CR26 and further ensures that CR is integrated within multiple disciplines working toward a common goal (ie, outpatient CR referral and participation). Of course, the inpatient PT in the cardiac setting must be cognizant of this opportunity and the role he/she plays in promoting outpatient CR participation. This writing group, particularly the members who are PTs, acknowledges that the proposed recommendations may represent a paradigm shift for current PT practice in the inpatient cardiac setting. However, such a paradigm shift has the potential to dramatically affect outpatient CR referral and participation in a positive manner.In summary, PTs in the inpatient setting have the potential to substantially improve outpatient CR referral given their established presence in the inpatient cardiac setting and their role in assessing functional capacity and determining discharge status and placement on discharge (ie, home, subacute rehabilitation facility).21–25 In addition to their primary role of assessing and improving functional status, the inpatient PT should provide education on the importance of outpatient CR participation to the patient. The inpatient PT should embrace the role of advocate for outpatient CR, educating patients on the value of participating in this important lifestyle intervention and ensuring that a referral has been secured on discharge.Clinical Exercise PhysiologistsCEPs frequently are members of the multidisciplinary team in CR programs.27 Although more likely to be involved in the outpatient program, the role of CEPs on the inpatient team is to provide expertise related to exercise prescriptions and training, physical activity recommendations, patient education, and exercise equipment. CEPs working in the inpatient setting are likely to have regular contact with inpatients either through formal educational sessions or by meeting one-on-one with inpatients; thus, there are ample opportunities to communicate the clinical benefits of participating in outpatient CR to patients eligible for this intervention. Consequently, CEPs should be knowledgeable about the outpatient program model, referral process, hours of operation, and other program details that may be helpful to patients. This provides a valuable link between the inpatient experience and the outpatient program.From an administrative perspective, if a CEP is employed by outpatient CR but also has responsibilities with an affiliated inpatient program, he or she can assist with monitoring the inpatient census and help to ensure that all eligible patients receive a referral to the outpatient program before discharge. This can be accomplished in a number of ways, including collecting paper referrals, verifying referrals in an electronic medical record, attending staff meetings on the appropriate inpatient units, and attending discharge planning meetings.Registered DietitiansGiven the poor nutritional patterns of a large percentage of patients suffering a cardiac event,28 medical nutrition therapy is an essential therapeutic component for the secondary prevention of CVD.29 The habitual diet of many cardiac patients falls far short of meeting the recommended dietary pattern for the secondary prevention of CVD.30 An extensive database demonstrates the efficacy of a dietary intervention; however, sustained adherence to dietary advice is necessary to achieve treatment goals.31 As reported by Artinian et al,32 the scientific literature describes impressive rates of initial behavior changes after a cardiac event, but frequently they are not translated to sustained behaviors.Registered dietitians (RDs) are uniquely qualified to provide medical nutrition therapy for cardiac patients by virtue of their training, expertise, and experience.33 The importance of RDs being an integral member of the medical team is acknowledged by the Adult Treatment Panel III, which recommends that RD referral be considered at each lifestyle therapy visit.29 Moreover, Van Horn et al34 recommend that patients with hypercholesterolemia be referred to an RD for medical nutrition therapy. Thus, RDs in the inpatient setting are in the position to educate patients on the value of outpatient CR and to advocate for referral on discharge. Because follow-up is required for a sustained nutritional behavior change, it is uniquely important for inpatient RDs to advocate for outpatient CR services. Thus, by doing their part in ensuring that eligible cardiac patients are referred and enrolled in outpatient CR, RDs can help patients achieve their long-term nutritional goals and facilitate their participation in other essential lifestyle interventions.PhysiciansThe fundamental design of inpatient care for the cardiac patient entails coordination between the physician and the above-described interdisciplinary team. Physicians involved in the care of cardiac patients may come from numerous disciplines (surgeons, interventionalists, primary cardiologists, primary care physicians, hospitalists, etc) with differing perspectives and priorities. However, all physicians, regardless of background and training, can share the common goal of promoting outpatient CR in eligible patients. Although day-to-day issues are addressed through a collaborative organization, the physician has distinctive tasks: He/she plays a unique role in facilitating patient intakes and individual treatment planning, performing patient assessments, and evaluating medical safety. Likewise, the physician's role and perspective are vital with respect to policies and procedures, and physicians must reinforce the value of outpatient CR and ensure the referral of all eligible cardiac patients. Smith et al35 previously demonstrated that a physician-endorsed, automated outpatient CR referral system results in higher rates of intake and enrollment. Conversely, Grace et al36 demonstrated that physician uncertainty as to which member of the healthcare team is responsible for securing an outpatient CR referral negatively affects eventual enrollment. Therefore, inpatient physicians should ensure that an outpatient CR referral system exists at their institution, identify the member(s) of the healthcare team responsible for securing the referral, and express strong support for the process. Physicians should also express their strong support for outpatient CR to all of the aforementioned health professionals involved in the care of cardiac patients and ensure that all members of the inpatient team discuss/endorse outpatient CR during their respective patient interactions. Moreover, in their own interactions with patients, their families, and other caregivers, physicians should convey the importance of outpatient CR to their recovery and strongly encourage participation, which in itself has been shown to improve enrollment.9 Finally, physician assistants and nurse practitioners, who often work very closely with physicians, should adopt the same principles and recommendations described in this section.The Continuum of Care: Home Health Nursing and PT in the Immediate Postdischarge PeriodAccording to recent estimates, roughly 7.6 million people in the United States receive community-based care,37 with a significant proportion receiving medical and therapeutic interventions at home. Moreover, the majority of home health patients are >65 years of age, a number that is expected to increase as the population ages. Not unexpectedly, the most frequent diagnoses are distributed across clients with endocrine and circulatory disorders. Nearly one third of home health patients present with diabetes mellitus and/or heart disease, ≈40% with hypertension, and two thirds with diseases of the circulatory system.38Poor referral and participation rates in outpatient CR programs are well documented in patients being discharged from the inpatient setting.15 Presuming that these low referral and participation rates in outpatient CR programs can be applied to home health patients, it is likely that a very low percentage of the population managed at home are being provided optimal interventions to help achieve the goals of preserving functional independence or maximizing secondary prevention. The benefits of outpatient CR are well established,39 so solidifying a continuity of care from home health to an institution providing outpatient CR is vitally important to reaching an ever-expanding group of patients in need of lifestyle modification.Because home health is often provided by nurses and PTs who focus on this population, potential avenues exist to expand the expertise of these practitioners in an effort to lay the foundation for eventual participation in outpatient CR, from both an educational and exercise training perspective, in the home setting. All patients would benefit from risk factor reduction and education; thus, they should be woven into the home health treatment plan. For the initial exercise training program, ECG monitoring via portable monitoring units or through telecommunication is feasible, and its use should be dictated by the clinical status of each individual patient. Even so, effective monitoring of vital signs, symptoms, and tolerance to exercise, combined with fundamental principles of exercise prescription, will serve the majority of nurses and PTs well in their overall management of the home health patient with chronic disease who will eventually be amenable to outpatient CR. It should be noted that not all patients treated in the home will become appropriate candidates for outpatient CR, and the clinical judgment of the nurse and/or PT should assist the physician in determining the correct therapeutic approach. However, referral and participation in outpatient CR should be a goal for all eligible patients once they are no longer homebound.Frequently, a time gap between acute care discharge and initiation of outpatient CR occurs, creating a break in the continuum of care. For patients receiving home health care, the nurse and/or PT should reiterate the components, benefits, and safety of outpatient CR to the patient that ideally were taught by the inpatient healthcare team and assist in facilitating an appointment, when appropriate, if one has yet to be made. Maintaining a continuum of care is an important concept that will improve patient perception that outpatient CR is not just a choice but an expectation for a complete recovery. Moreover, many barriers contribute to why patients do not attend CR, including a lack of access, transportation issues, perceived inconvenience, caring for a spouse or others in the home, and financial need to return to work.15,17,40,41 The home health nurse and/or PT can often provide resources and/or strategies that may help the patient overcome these barriers. Finally, although the roles and responsibilities of the home health nurse and PT may differ, the unifying themes described previously for inpatient health professionals certainly apply to this setting as well.A number of established outpatient CR programs incorporate home health in their range of services.42 Training and support for home health nurses and PTs to effectively manage their patients with appropriate CR strategies can be readily provided by outpatient CR program staff. Such collaboration is also likely to facilitate the transition from home health care to outpatient CR enrollment at the correct juncture of a patient's recovery.Key RecommendationsThe process of identifying key personnel to direct and implement early inpatient CR, to educate about outpatient CR, and subsequently to facilitate patient entry into an outpatient CR program is dependent on the resources of the inpatient setting, including administrative structure, available personnel and their philosophical approach, and various economic and regulatory considerations. Ideally, there should be a smooth transition from inpatient to outpatient CR programming, but this is likely dependent on the initial administrative designations of responsibilities. The Table provides recommendations for inpatient CR programs that would facilitate referral and participation in outpatient CR.Table. Recommendations for Inpatient Health Professionals to Improve Referral to Outpatient Cardiac Rehabilitation*Formulation of a multidisciplinary inpatient CR program to Assess and prepare patients for discharge home and eventual participation in outpatient CR Share relevant patient status and progress information during inpatient CR with all relevant inpatient healthcare professionals Help to identify patients not ready for the initiation of exercise or participation in outpatient CR and patients at risk for functional decline, depression, anxiety, or other psychological or social problems that may hinder acute, subacute, or long-term rehabilitation progress; consider referral to home health therapy as a bridge to outpatient CR in these patientsInitiation of an automatic referral to appropriate inpatient health professional(s) to assess the readiness of all patients with a cardiac event for discharge home and for participation in an outpatient CR program via A functional assessment with a functional performance measure (ie, 6MWT, TUG) to examine functional status directly and to enable the prescription of assistive devices and exercise as indicated, and performance of a submaximal exercise test via low-level treadmill or cycle ergometry exercise in appropriate patients† Use of generic (ie, SF-12 or SF-36) and/or specific (i.e., MLWHFQ, Duke Activity Scale) functional status questionnaires to examine perceived functional status Assessment of self-efficacy (ie, Cardiac Self-Efficacy Scale) Nutritional assessmentDevelopment and examination of evidence-based multidisciplinary models of discharge planning with a focus on Educating all inpatient health professionals on the methods to implement the above items Educating all inpatient health professionals on the interpretation of the above items and developing different methods to improve referral to outpatient CR once acute, subacute, or long-term rehabilitation hospitalization is complete Increasing referrals and participation in outpatient CR Consider implementing quality indicators to objectively track outpatient CR referral performanceCR indicates cardiac rehabilitation; 6MWT, 6-minute walk test; TUG, timed up-and-go; SF-12, Medical Outcomes Short Form-12; SF-36, Medical Outcomes Short Form-36; and MLWHFQ, Minnesota Living With Heart Failure Questionnaire.*The functional assessment, submaximal exercise test, and inpatient CR program should use all methods outlined in the American Association of Cardiovascular and Pulmonary Rehabilitation cardiac rehabilitation guidelines, including monitoring of symptoms, vital signs, and ECG in appropriate patients, as well as American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association performance measures for cardiac rehabilitation.10,11,27†The American Heart Association and American College of Cardiology have previously described patients who may be appropriate for low-level exercise testing.39,43,44At the outset of the planning process, it is important to develop an inpatient CR structure that is led by an individual (inpatient CR director) who possesses a strong background in CVD prevention and rehabilitation, including exercise training, CVD risk factor and behavioral modification, and program development. The interpersonal skills necessary to direct personnel from various health care disciplines, such as nursing, PT, CEP, and dietary, are also essential. In addition, the inpatient CR director must be an enthusiastic advocate for outpatient CR in interactions with facility administrators and all other healthcare professionals involved. There are a number of CR-related publications that the inpatient healthcare team should thoroughly review. Perhaps two of the most important documents that all healthcare team members should understand completely, particularly the inpatient CR director, are the "AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services: A Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation)"11 and the earlier 2007 publication.10 These publications advocate the use of a performance measure to assess outpatient CR referral patterns from the inpatient setting, a practice the current writing group strongly endorses. Other publications detail the process for developing an automatic referral to outpatient CR, which is also strongly endorsed by the current writing group.45 Finally, publications invaluable in developing the policies and procedures for both inpatient and outpatient CR include the American Hea
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