how did we get here and where do we go now? karen lui, rn, ms grq, llc karen@grqconsulting.com nccra...
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How Did We Get Here and Where Do We Go Now?
Karen Lui, RN, MSGRQ, LLC
karen@grqconsulting.comNCCRA
March 2, 1012Chapel Hill, NC
1950’s - Pioneer Research• Our giants of 1950’s-1960’s included past
award recipients Drs. Sam Fox, Herman Hellerstein, Nanette Wenger, William Haskell, Gerald Fletcher…
• From bedrest to activity post-MI…• Safety of exercise for heart patients was
established (Haskell, 1978; others).• National Exercise & Heart Disease Project
(NEHDP-1973-1980) assessed mortality & morbidity of post MI patients receiving CR.
A treatment was emerging with establishment of hospital, clinic, and community-basedexercise programs.• Univ of WI-Madison (1965-Balke)• CAPRI (1968-Pyfer)• Toronto Rehab Center (1968-Kavanagh)• YMCArdiac Therapy model (1970-Berra)• Denver Pulmonary Rehab (1966-Petty)• UCSD (1970-Moser)
1960’s - Pioneer Programs
• Wake Forest Univ– Dr. Mike Pollock, Dr. Paul
Ribisl– MS degree program-1978
• Univ of WI-La Crosse– Philip K. Wilson, EdD– MS degree program-1978
• AACVPR founded by interested group of ACSM members in 1985
1970’s - An Emerging Profession
• Concept of inpatient rehab was emerging with reimbursement now obtainable.
• Outpatient CR– Sq footage wasn’t typically factored into cost– RN salaries were appropriate to staff CR– Covered for 12 months post DC • 72-78 sessions
– Programs were profitable for hospital
Cardiac Rehabilitation 1975
Cardiac Treatment Centers (CTC)• Set up 120 hospital outpatient CR
programs• CTC nurses were given 3-4 weeks of CR
training and then certified by CTC
Cardiac Rehabilitation 1975
Outpatient CR• Group of 4-8 patients• Group warm-up & cool-down• Group exercise with intermittent rest and/or
circuit – TM, stationary bike, arm ergometer• Nurse-dictated settings• Pulse check
Cardiac Rehabilitation 1975
• 1976-protesting for the right to be a nursing student in MA (thanks to Massachusetts chapter of ANA)
• 1978-CCU for post MI patients: no “chair” privileges, no hot beverages, no rectal temps, etc.
• Take the CCU defibrillator to the YMCA 3x/wk
Where were you when…?
• Inpatient CR services no longer reimbursed by Medicare
• Outpatient CR-36 session limit
• Growth in CABG procedures and in CR programs (basement)
Cardiac Rehabilitation 1985
Dr. Nanette K. WengerEmory Univ School of MedicineDirector, Cardiac ClinicsGrady Memorial Hospital, Atlanta
1986 AACVPR Keynote:Future Directions for
Cardiovascular Rehabilitation
• 1989: CMS (then HCFA) - requirement for a physician in the exercise room during cardiac rehab,
• Dr. L. Kent Smith, Dr. Barry Franklin & other AACVPR leaders, with other organizations, succeeded in getting this requirement rescinded!
Early Advocacy
Our practice changed in response to science:• Depression screening tool was added to our
assessment,• Educational/counseling shifted from classes-
for-all to based on each patient’s readiness to change,
Cardiac Rehabilitation 1995
• Resistance training became part of our phase II CR exercise prescription,
• Heart rate monitoring devices enhanced self exercise progression,
• More focus on promoting self-efficacy strategies for better long-term patient outcomes.
Cardiac Rehabilitation 1995
• Untoward event data recognized as important to track and report;– Carl King, EdD
• Computer software allowed better tracking of patient outcomes. – Mark Lui, MS
Co-Director & Computer Programmer, SWFHG
Cardiac Rehabilitation 1995
Classes were changed to open gym model to:• Allow more slots per day• Provide flexible scheduling similar to what
patients would encounter after Phase II• Improve adherence and patient satisfaction
Cardiac Rehabilitation 1995
Classes were changed to open gym model to:• Tailor duration to individual’s progression
tolerance • Encourage daily exercise regimen• Allow an accelerated option for program
participation with appropriate patients
Cardiac Rehabilitation 1995
• Resistance training-safe & beneficial for cardiac patients– Pollock, Franklin, Balady, Ades, others
• And for pulmonary rehab patients– ACCP/AACVPR Pulmonary Rehabilitation
Clinical Practice Guidelines (2007)
Cardiac Rehabilitation 1995
Relationship between depression and heart disease was emerging.
James A. Blumenthal, PhD (& others) 2002 AACVPR Established Investigator Award
Cardiac Rehabilitation 1995
• AACVPR (Pat Comoss, President) secured AACVPR contract with Agency for Health Care Policy and Research (AHCPR)/NHLBI to develop Clinical Practice Guidelines for CR, based on science,
• Defined CR as a secondary prevention intervention with emphasis on comprehensive risk factor management and exercise therapy.
Clinical Practice Guidelines for CR1995
• Transtheoretical Model of Behavior Change by Prochaska & DiClemente,
• Self-Efficacy concept by Bandura (1960’s),• Behavior change models were emerging
that demonstrated more effective ways to help patients change behaviors.
Cardiac Rehabilitation 1995
State collective outcomes project tracked exercise progression:
• Outcomes differed in frequency, intensity, & duration between “progressive” and “conservative” approaches,
• Programs that began to measure outcomes were likely to change in response to findings.
Cardiac Rehabilitation 1995
Patient profiles have changed, i.e., older, less fit, more diabetes/metabolic syndrome, more obesity.
-Evans J, Bethell H, Turner S et al. Characteristics of patients… JCRP, 2011;31:181-187. -Audelin MC, Savage PD, Ades PA et al. Changing clinical profile of patients… JCRP, 2008;28:299-306.
Cardiac Rehabilitation 2010
Research demonstrates better patient outcomes by optimizing the exercise intervention.
• High-calorie expenditure exercise-Ades, Savage, Toth et al, Circulation, 2009;119;2671-2678.
• 1% increase in peak VO2 predicts 2% decline in CV mortality-Vanhees et al, JACC, 1994
• Peak aerobic capacity (METs) strongest predictor of risk of death for subjects with and without CV disease-Myers et al, NEJM, 2002; Keteyian et al, AHJ, 2008
Cardiac Rehabilitation 2010
• CAD is now recognized as a disease on a continuum and lines between “phases” are less delineated-
• Same patient population with same long-term exercise and behavior change goals to address disease progression.
Cardiac Rehabilitation 2010
CR is now less restricted by regulatory limitations and is able to deliver services using more clinically-effective models:• Medicare-required non-exercise components• Medicare reimbursement for non-ECG monitored
exercise• More flexibility in delivery of sessions, individualized
for each patient
Cardiac Rehabilitation 2010
• Individualization of treatment plan is now required by Medicare, based on measurable goals.
• We now know short-term goals for modifying risk factors is most effective when based on the patient’s readiness for change.
Cardiac Rehabilitation 2010
• CR referral is on track to be a Medicare core measure, leading to systematic evaluation for CR,
• EMR will enhance this systematic process,• Increased referrals will demand increased
program capacity and expansion to provide services to broader range of CAD patients.
Cardiac Rehabilitation 2010
The CR team needs to specify goals…as measurable physical, behavioral, and risk factor outcomes linked to clinical outcomes. If this is done effectively, the combination of rehabilitation and secondary prevention will become the standard of care for patients with coronary heart disease.
“Cardiac rehab and secondary prevention of CHD”. NEJM, 2001:345;892-902. Dr. Phil Ades, Award of Excellence recipient, 2006
Cardiac Rehabilitation 2010
• AACVPR Program Certification-1998–Carl King chaired effort that led the
field to outcomes measurement• Clinical Competency Guidelines for
Pulmonary Rehabilitation-2007–Nici, Limberg, Hilling, Carlin,
Normandin
Significant AACVPR Steps inAdvancing the Profession
• Core Components of CR/Secondary Prevention Programs-2007–Balady, Williams, Ades, Bittner,
Comoss, Franklin, Sanderson• AACVPR Cardiac Rehabilitation Core
Competencies-2010–Hamm, Sanderson, Ades, Kaminsky,
Roitman, Williams
Significant AACVPR Steps inAdvancing the Profession
• Performance Measures on CR for Referral/Delivery of CR/Secondary Prevention Services-2007– Thomas, King, Oldridge, Spertus, Pina
• Performance Measures for PR: Quality of Life and Functional Capacity-2010–Garvey, Bauldoff et al
Significant AACVPR Steps inAdvancing the Profession
• CR and PR services are strengthened through a multi-disciplinary approach.
• Early 1990’s: AACVPR pursued program certification over individual certification for CR/PR providers = good decision.
Important Next Steps-Individual Accreditation
• Core competencies define a set of measureable indicators required for minimal expectations for performance,
• Program core components define specific information/skills necessary to provide evidence-based care in CR programs.
Important Next Steps-Individual Accreditation
• There are no “continuing education requirements” specific to CR/PR to provide the knowledge and skills that core competencies call for the rehab team to have.
• There are limited resources available for practitioners to obtain the specific knowledge and skill set for this profession.
Important Next Steps-Individual Accreditation
AACVPR is currently examining need for individual accreditation process specific to CR/PR services.
Important Next Steps-Individual Accreditation
• What should program certification represent in 3-5 years?– Valuable QI experience– Standard of Care
• Is AACVPR ready to promote program certification as a factor to be considered in payer reimbursement decisions?– What if CMS asked that question today?
Important Next Steps-Program Certification
• CR and PR-endorsed performance measures now exist.
• Payers are moving toward performance-based reimbursement:– Pay for Performance– Hospital-Associated Conditions– Intensive Cardiac Rehabilitation
Important Next Steps-Program Certification
AACVPR Program Certification will: • Be based primarily on outcomes-based
criteria• Be well-integrated with science, i.e.,
Guidelines & Registry • Include “qualified team” criteria, based
on core competencies
Important Next Steps-Program Certification
• Gaps between science and practice are not unique to CR and PR.
• Practice depends on evidence.• Apply the evidence-based practice
guidelines to your practice• Modernize your delivery model to
maximize efficiency• Identify and achieve meaningful outcomes
Science and Practice
• Liaison efforts between professional organizations is beneficial– J-11 MAC Committee and AACVPR
• On-going communication with policy makers regarding significant research is important– Recognition by CMS that cardiac and pulmonary rehab
are comprehensive services– Adoption by providers and payers of evidence in
demonstration projects and emerging coverage policies
• Continue to make your administration aware of scientific findings, national guidelines, program outcomes
Advocacy and Science
• Ability to provide CR without a physician required to- –Be in the exercise room,– Sign every ECG strip!
• Expansion of Medicare-eligible diagnoses in 2006
Advocacy and Practice
• Budget requires attention to opportunities for program growth and expansion of services,
• Current inefficiencies in program delivery should be addressed to improve your program’s bottom line.
Practice and Budget
• Practice can better reflect the science,• Practice can focus on what’s important,• Programs can respond to changing
delivery and patient needs.
A Time of Great Opportunity
• Question why you do what you do, • Question how your practice might change
to better reflect current research,• Move your program toward collecting
meaningful outcomes, based on the direction our AACVPR Registry steers us.
• Thank our giants and heed their findings, recommendations, and vision.
In Conclusion…
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