Beyond Phase 1 of Cardiac Rehabilitation

Overview of cardiac rehabilitation and its significance in the recovery process.
Importance of rehabilitation professionals in facilitating patient recovery.
Discussion of various stages of rehabilitation post-acute care:
- Discharge planning
- Transitional phases before entering structured outpatient programs

Significance of determining appropriate discharge destinations after medical stabilization.
Physical therapy evaluation to assess mobility and safety during discharge:
- Activities evaluated include vital sign responses to mobilization, cardiac rhythm, balance, and mobility tasks (e.g., stair negotiation).
Considerations for discharge: physical capabilities and home environment suitability.
Patients can return home if:
- They demonstrate adequate physical capacity.
- They have a supportive home environment.
In cases where home discharge is not feasible or safe:
- Physical therapists (PTs) evaluate options for more structured rehabilitation settings.

Inpatient Rehabilitation Facility (IRF):
- Most intensive rehabilitation option.
- Engagement in 3 hours of therapy per day lasting 1.5 to 3 weeks.
- For medically stable patients who can handle high-intensity therapies.
Skilled Nursing Facility (SNF):
- Offers lower intensity therapy over extended periods.
- Facilitates patient progress at a comfortable pace.
Long-Term Acute Care Hospital (LTAC):
- Provides specialized care for patients needing extensive stabilization time.
- Transitioning patients to SNF or home following stabilization is key.
Home Health Agency:
- For patients discharged home but unable to attend outpatient rehab.
- Provides therapy through a PT at home.

Settings after acute care but before outpatient rehab referred to as Phase 1.5.
Distinguishes itself from Phase II, which is defined as early outpatient rehabilitation.
Goal: Transition between intensive monitoring of Phase 1 and structured, goal-oriented programs in Phase II.

Outpatient cardiac rehab supported as a Class I Level A recommendation.
Proven effectiveness demonstrated through high-quality evidence and clinical trials.
Benefits include:
- Reduced all-cause mortality and cardiovascular mortality.
- Lower hospital readmission rates.
- Improved exercise capacity, symptoms, and quality of life for patients.
Backed by major guidelines from the American Heart Association, American College of Cardiology, and European Society of Cardiology as the gold standard for secondary prevention, essential for enhancing cardiovascular health and overall well-being.

Conditions Qualifying for Medicare/Medicaid Coverage (per Centers of Medicare and Medicaid Services guidelines):
1. Myocardial infarction within the last 12 months
2. Coronary Artery Bypass Graft (CABG) surgery
3. Stable angina
4. Angioplasty
5. Heart or lung transplantation
6. Heart valve repair or replacement surgery
7. Stable chronic heart failure
Exclusions:
- Peripheral arterial disease (not qualifying for cardiac rehab coverage)
- Patients with specific health issues preventing safe exercise, including:
- Recurrent ischemic pain
- Uncompensated congestive heart failure
- Resting heart rates outside normal (tachycardia over 100 bpm or bradycardia below 50 bpm)
- Uncontrolled hypertension (systolic BP > 180 mmHg)
- Other health conditions rendering exercise unsafe or unnecessary
Lower-risk individuals may be better served in primary prevention programs instead of cardiac rehabilitation.

Medical Director:
- Ensures program effectiveness and safety.
- Collaborates with team members to align patient care with best practices.
Program Coordinator:
- Central role in managing personnel and program operations.
- Develops policies, manages budget, evaluates program needs.
Exercise Training Professional:
- Experts in exercise physiology and pathology.
- Skilled in monitoring equipment and safe exercise practices.
- Trained in advanced cardiac life support including defibrillation.
Registered Dietitian:
- Provides tailored nutritional assessment and counseling.
- Supports dietary changes to enhance cardiovascular health.
Behavior Specialist:
- Addresses psychological and behavioral aspects of rehabilitation.
- Employs evaluation and counseling techniques to support lifestyle changes.
Vocational Counselor:
- Guides patients in returning to work or exploring new job opportunities.

PTs contribute significantly to exercise prescription, education, and long-term management.
Goals of Outpatient Cardiac Rehabilitation:
- Improve cardiovascular function
- Reduce modifiable risk factors
- Provide education for sustainable health behavior changes
- Ensure safe reintegration into daily life, work, and recreational activities
Individualized programming integrates multiple components:
- Smoking cessation
- Nutritional counseling
- Psychosocial well-being management
- Managing hypertension, diabetes, and lipid disorders
PTs monitor exercise intensity and responses to maintain safety and effectiveness:
- Relying on objective testing data from exercise testing.
- Structuring progression that balances aerobic training and strength exercises.
PTs assess physical demands and provide graded exposure to activities for returning to work or recreational aspects, facilitating adaptations necessary for patients with cardiac limitations.
Educating patients and their families on exercise adherence and lifestyle changes enhances compliance and support systems for long-term success.

Emphasizing self-monitoring and patient independence as they progress.
Monitoring for:
- Arrhythmias
- Abnormal cardiovascular response to activity
- Signs of exercise intolerance (e.g., angina, dizziness)

Cardiac rehabilitation programs progress based on patient abilities and physiological responses rather than fixed timelines.
Factors such as medical stability determine when a patient can start and advance in rehab.
Importance of individualized approaches to rehabilitation based on unique clinical status and responses, contrasting with time-based protocols in other rehabilitation settings.