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Figure 1: Cardiac Rehabilitation Services Across the
referral has been made. Sufficient information needs to be given to the
patient to allow him or her to easily enroll in CR. Unfortunately, earlier
versions of referral measures did not include the requirement for
adequate communication and did not effectively increase CR
participation. For example, data from a large teaching hospital in Boston
Address high-risk behaviors revealed that although referral to CR increased to 55% during a quality
Referral to outpatient CR
improvement project, only 19% actually enrolled.
Approximately 25% of
patients, when contacted after hospital discharge, did not remember
being referred to CR.
For this reason, the current CR performance
measures define a referral as: “an official communication between the
health care provider and the patient to recommend and carry out a
CR in IRF for elderly
referral order to an early outpatient CR program. This includes the
provision of all necessary information to the patient that will allow thePT/OT to improve gait and ADLs
Goal—independence at home
patient to enroll in an early CR program. This also includes a
communication between the health care provider or health care system
and the CR program that includes the patient’s referral information for
These referral-to-CR performance measures have been incorporatedIndividualized treatment plans
Communication with other healthcare providers
into the ACC/AHA Performance Measure Set for Non-STEMI/STEMI
Develop lifelong strategies for secondary prevention
Assessment of individual and program outcomes and into quality improvement registries such as the National
Cardiovascular Data Registry (NCDR).
AACVPR has provided members
with a referral enhancement toolkit that includes sample order sets,
scripts, data tracking, marketing tools, and PowerPoint presentations to
use with professional and lay audiences.
Alternative delivery models
Some healthcare systems use CR staff to evaluate and mobilize patientsTelemedicine
Advance nurse-led, peer-facilitated
after acute cardiac events or open-heart surgery, which can enhance
understanding about the importance of participating in CR. Other
centers are incorporating a referral to CR field in electronic discharge
order sets for patients with qualifying discharge diagnoses.
Continued secondary prevention programs
Barriers to Enrollment in Cardiac Rehabilitation
Hospital-based supervised exercise and support groups
Despite progress in developing systems to enhance referral, however,
Community-based exercise and support groups
Internet-facilitated home programs
significant barriers to enrollment remain, especially for the elderly,
women, and minorities.
ADL = activities of daily living; CR = cardiac rehabilitation; IRF = inpatient rehabilitation facility;
Increasing Enrollment of Elderly PatientsOT = occupational therapy; PT = physical therapy.
Elderly patients clearly benefit from CR and the percentage
to promote quality improvement efforts by healthcare systems and improvement actually exceeds that for younger individuals.
These measures were intended to enhance care often an under-referral bias, in part because physicians and other
co-ordination by promoting referral to CR as well as by defining minimal healthcare providers are not aware of the benefits and do not realize
standards for quality CR programming. that newer treadmills and recumbent bicycles provide low-intensity
exercise appropriate for elderly patients.
CR begins during the acute care hospitalization of patients with
cardiovascular disease. As length of stay has decreased, by necessity Depression, social isolation, decreased endurance and strength, and
inpatient CR has focused on mobilization and identification of high-risk decreased functional capacity for activities of daily living are real
behaviors, such as tobacco use. Often there is insufficient time and problems for these patients. CR programs address and improve all of
opportunity to address other secondary prevention issues during these issues.
Family support and transportation are often barriers to
inpatient rehabilitation, such as nutrition, weight loss, adherence to participation and creative use of community resources may be needed.
preventive medications, and regular aerobic exercise. Fortunately, these
issues are stressed during outpatient CR programs.
Systems are often Fortunately, Medicare recognizes the benefits of CR, including its
lacking, however, to ensure that patients enroll in CR after discharge. comprehensive nature. The most recent coverage determination policy
includes patients with recent open-heart surgery, including valve or
Effective referral includes communication between the referring coronary bypass surgery, percutaneous intervention, myocardial
healthcare provider, the patient, and the CR program organizer that a infarction, or transplantation.
This policy also extends the maximum
80 US CARDIOLOGY