how did we get here and where do we go now? karen lui, rn, ms grq, llc [email protected] nccra...

How Did We Get Here and Where Do We Go Now?

Karen Lui, RN, MSGRQ, LLC

[email protected]

March 2, 1012Chapel Hill, NC

mailto:[email protected]

How did we get here?

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


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


• 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)


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,


• 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.


• 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


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


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


• 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)


Relationship between depression and heart disease was emerging.

James A. Blumenthal, PhD (& others) 2002 AACVPR Established Investigator Award


• 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.


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.


Where are we?

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.


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


• 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.


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


• 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.


• 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.


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


• 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


• 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


Where do we go now?

• 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.


• 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.


AACVPR is currently examining need for individual accreditation process specific to CR/PR services.


• 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


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


Science Practice

Advocacy Budget

The Table of Balance

• 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

Pulmonary rehab payment issue iscritical to the survival of this

service.

Advocacy and Budget

• 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…

how did we get here and where do we go now? karen lui, rn, ms grq, llc [email protected] nccra...

Documents

cr exercise prescription

medicareoutpatient cr

exercise room

hospitalcardiac rehabilitation

heart patients

ctccardiac rehabilitation

inpatient cr services

weeks of cr training