Exercise and Leadership Chapter 4

Coronary Artery Disease

Is the leading cause of death and disability in the United State

Cardiac Rehabilitation Programs

Secondary Prevention services, help to slow, stabilize or reverse the atherosclerosis process, resulting in a reduction in the risk of future cardiovascular events. Play a critical role in acute and chronic care of the patients with CAD and have demonstrated powerful reduction in morbidity (disease) and mortality (death) benefits.

Mortality Reduction with Exercise-based rehabilitation

27%, which is most comparable to the effects of our most potent pharmacologic agents (medicines)

Aims of Cardiac Rehab programs

Optimize cardiovascular risk reduction. Promote adoption and adherence to healthy lifestyle behaviors. Reduce disability. Promote an active lifestyle for patients with cardiovascular disease.

Heart-related medical conditions (Eligible Participants for Cardiac rehab)

• myocardial infarction
• coronary artery bypass grafting
• chronic stable angina pectoris
• percutaneous coronary intervention
• congestive heart disease
• heart transplant
• valvular surgery
• arrhythmias

Phases of Cardiac Rehab

I: in-hospital
II: outpatient with close supervision and ECG monitoring
III/IV: long-term maintenance

Phase 1: In-hospital (for success)

Important intervention that is needed during the brief hospitlization of patients who have had a myocardial infarction (MI) Identifying and contacting patients in hospital and developing a computerized referral porcess to outpatient Cardiac rehab will enhance the likelihood that the individual will participate in cardiac rehab

Intervention needed during brief hospitilzation of patients who have MI

Patients need to be directed to an outpatient (Phase ii) program. Continued smoking cessation and relapse prevention needs to be addressed for individuals who were smoking priot to their hospitilzation. Cardiovascular risk factors should be defined and reviewed. Follow up appointments need to be scheduled.

Reasons for the Low utilization rate of cardiac rehabilitation (why people don’t use it)

Geographic inability to access a program. Inadequate insurance coverage. Cost. Work and family conflicts. Only about 50% of individuals who complete Cardiac Rehab are adhering to an exercise regimen at 1 year.

Pulmonary Rehab

Evidence Based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities

Obstructive Lung (Pulmonary Participants)

Chronic Obstructive Pulmonary Disease. Asthma, Cystic Fibrosis, Brochiectasis, Emphysema

Restrictive Lung Diseases (Pulmonary Participants)

Pulmonary Fibrosis, Interstitial, lung disease, Sarcoidosis, Occupational or environmental lung disease.

Chest wall diseases (Pulmonary Participants)

Kpyhscoliosis. Ankylosing spondylitis

Neuromuscular Diseases (Pulmonary Participants)

Parkinson Diseases, Multiple Sclerosis, Amyotrophic lateral sclerosis, Post-polio syndrome, Post-tuberculosis syndrome.

Pulmonary Benefits

Improves the symptons of dyspnea (breathing). Improves health-related quality of life. Reduces hospital days and other healthcare utilization measures. Provides psychosocial benefits.

Pulmonary Rehab recommended programs

Program of exercise training that includes both low and high intensity endurance training.

Resistance training to increase muscle strength and mass

Use of supplemental oxygen during exercise for patients with exercise-induced hypoxemia (low oxygen in blood)

Prevention and treatment of disease aggravation

Cardiac and Pulmonary Rehab program can be conducted where

An inpatient, outpatient, home-based, or community-based setting

Facilities and Equipment. Concerns on Cardiac and Pulmonary Rehab programs

Must meet state, federal, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) safety standards or other regulatory agency standards as appropriate. Must consider space for exercise testing and training, patient consultations, psychosocial evaluations, confidential storage of patient medical records (EMRs help), and administrative and staff member offices

Weight Bearing (Exercise Equipment)

Treadmills, stairs, stair-steppers, elliptical trainers

Non-weight bearing Modalities (Exercise Equipment)

Recumbent cycles, arm ergometers, stationary and wind-resistance cycles, and rowing machines.

Resistance Modalities (Exercise Equipment)

Machine weights, free weights, dumbbells, cuff weights and wall pulleys

Administrative concerns for Cardiac/Pulmonary Rehab programs

All programs must have policies and procedures in place with routine re-evaluation, Documentation of all program activities, including those of patient care, must be performed. AACVPR implements a certification program for both cardiac and pulmonary programs

Workers of Cardiac and Pulmonary Rehab programs

Healthcare team (Medical Director). Program Director/Coordinator (Typically a nurse or exercise or science professional. Multidisciplinary healthcare professionals (Clinical exercise physiologist, Clinical exercise specialist, registered nurse, respiratory therapist, registered dietitian).

Medical Director

role of the medical director, as leader of the multidisciplinary team, is to assure that the Cardiac and Pulmonary Rehab program is safe, comprehensive cost-effective, and medically appropriate for the services provided.

Program Director/Coordinator

Has administrative, clinical, and educational duties and works in collaboration with the medical director in all aspects of Cardiac and Pulmonary Rehab management and program operation.

Case Management

an integrated approach to provide individualized care for patients with chronic disease, including cardiac, pulmonary, and other chronic diseases.

Components of Case management include

– Patient intake evaluation
– Risk stratification
– Care or treatment plan
– Exercise prescription and exercise training
– Education and counseling
– Discharge plan

Process of Care

Allows the staff to develop a rapport with the patient, to monitor and evaluate patient progress, and to facilitate communication among other healthcare providers

Five needs that is most appropriate for the patient

1) frequency
2) intensity
3) duration
4) mode
5)rate of progression

Goal of discharge planning

to review the outcomes achieved and develop a specific plan to facilitate patients as they transition from a more intensively monitored situation to a self-management phase

Outcome Assessment and Quality improvement

Important to identify outcome measures that reflect the care in the following domains such as Clinical, Behavioral, Health, and Service

93793 (Current Procedural Terminology (CPT) code that are appropriate to cardiac rehab)

physician services for outpatient program without continuous ECG monitoring

93798 (Current Procedural Terminology (CPT) code that are appropriate to cardiac rehab)

physician services for outpatient program with continuous ECG monitoring

Pulmonary Rehab Services

provided under different CMS reimbursement mechanisms. At this time, there are CPT and G-codes (e.g., GO237, GO238, and GO239) that are used for many inpatient or outpatient PR services

Reimbursement and Financial Considerations

Centers for medicare and Medicaid Services (CMS). Other insurance providers, Expanding Populations and self-pay services

Other insurance providers (Reimbursement and financial considerations)

Variable coverage for reimbursement levels, number of sessions allowed, ETC. May include co-pays.

Expanding populations and self-pay services (Reimbursement and financial considerations)

Appropriate locations and personnel for addressing those at high risk for cardiac, pulmonary, and other chronic diseases such as diabetes, hypertension, obesity, etc.

Concerns for Cardio and Pulmonary Rehab

Challenges and future directions
–Low use levels
–Eligibility
–Poor completion rates