1. Cardiac Rehab Roundtable
HHQI 2018 HEART MONTH WEBINAR
Cardiac Rehab Roundtable
FEBRUARY 27, | 2:00-3:30PM ET
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy.
Publication number 11SOW-WV-HH-MMD

2. Continuing Education Credits
Nursing: 1.75 hrs of Continuing Education
Approved by the Alabama State Nurses Association,
an accredited approver by the American Nurses
Credentialing Center’s Commission on Accreditation
Physical Therapy: 1.0 Continuing Competency Units (CCUs)
Approved by The Federation of State Boards of Physical Therapy
To receive CE credit, participants must:
Watch the 90-minute webinar
Enroll in the corresponding course in HHQI University
Complete the evaluation (15 minutes)
Step-by-step instructions will be reviewed at the end of today’s webinar.

3. Today’s Objectives
Describe two of the Million Hearts 2022® cardiac rehabilitation priorities.
Explain three benefits and potential barriers of outpatient cardiac rehabilitation.
Discuss two alternatives for the home health setting when outpatient cardiac rehab is not possible.
List three methods to improve home health patients’ cardiac rehabilitation participation.

4. Today’s Panel of Experts
Janet Wright, MD, FACC CDC/CMS; Million Hearts® Executive Director
Kate Traynor, RN, MS, FAACVPR Massachusetts General Hospital Director, CVD Prevention Center
Bud Langham, PT, MBA Encompass Home Health Chief Clinical Officer

5. Keeping People Healthy
Million Hearts® Aim: Prevent 1 Million Heart Attacks and Strokes in 5 Years
Keeping People Healthy
Optimizing Care
COMMUNITY
Priority Populations

6. Million Hearts® 2022 Priorities
Keeping People Healthy
Reduce Sodium Intake
Decrease Tobacco Use
Increase Physical Activity
Optimizing Care
Improve ABCS*
Increase Use of Cardiac Rehab
Engage Patients in Heart-healthy Behaviors
Improving Outcomes for Priority Populations
Blacks/African Americans with Hypertension
35- to 64-year-olds due to rising event rates
People who have had a heart attack or stroke
People with mental illness or substance use disorders
To prevent one million heart attacks and strokes by 2022, we need to focus on three key priorities:
First - Keeping people healthy by making changes to the environments in which people live, learn, and work to make it easier for people to make healthy choices, particularly though a 20% reduction in sodium intake, tobacco use, and physical inactivity
Second - Optimizing care so that those with and at risk for cardiovascular disease receive the services needed to reduce the likelihood of having a heart attack or stroke.
This includes achieving 80% performance on the ABCS – aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation;
Having 70% of eligible patients participate in cardiac rehabilitation
And trying to improve patient engagement in their cardiovascular health
And third - Improving outcomes for priority populations who suffer worse outcomes of cardiovascular disease and where there is evidence and the opportunity to make a significant impact. This has been established as a new priority for this phase of Million Hearts.
*Aspirin use when appropriate, Blood pressure control, Cholesterol management, Smoking cessation

7. Keeping People Healthy
Goals
Effective Public Health Strategies
Reduce Sodium Intake
Target: 20%
Enhance consumers’ options for lower sodium foods
Institute healthy food procurement and nutrition policies
Decrease Tobacco Use
Enact smoke-free space policies that include e-cigarettes
Use pricing approaches
Conduct mass media campaigns
Increase
Physical Activity Target: 20%
(Reduction of inactivity)
Create or enhance access to places for physical activity
Design communities and streets that support physical activity
Develop and promote peer support programs
Preventing 1 million events is possible by achieving a 20% reduction in sodium, smoking, and physical inactivity in our communities.
Strong evidence suggests local food procurement policies can enhance consumer choice for lower sodium foods, while encouraging more producers to offer lower sodium alternatives.
Smoke-free spaces and pricing approaches are effective in driving down tobacco use.
And there is promising evidence that increasing access to places for physical activity, designing communities and streets with physical activity in mind, and peer support–type walking groups can help more individuals increase their physical activity level.

8. Optimizing Care High Performers Excel in the Use of… Improve ABCS*
Goals
Effective Health Care Strategies
Improve ABCS*
Targets: 80%
High Performers Excel in the Use of…
Teams—including pharmacists, nurses, home health and community health workers, and cardiac rehab professionals
Technology—decision support, patient portals, e- and default referrals, registries, and algorithms to find gaps in care
Processes—treatment protocols; daily huddles; ABCS scorecards; proactive outreach; finding those with undiagnosed high BP or cholesterol, tobacco use, PM2.5 exposure
Patient and Family Supports—training in home blood pressure monitoring; problem-solving in medication adherence; counseling on nutrition, physical activity, tobacco use, risks of particulate matter; referral to community-based physical activity programs and cardiac rehab
Increase Use of Cardiac Rehab
Target: 70%
Engage Patients in Heart-healthy Behaviors
Targets: TBD
Likewise, in order to achieve excellence in clinical care, Million Hearts® 2022 partners are working to achieve 80% performance on key clinical quality measures of cardiovascular care. These are the ABCS:
Aspirin use or other anticoagulants as appropriate,
Blood pressure control,
Cholesterol management, and
Smoking cessation.
Acknowledging the deeply rooted science in support of cardiac rehab, the importance of the service in preventing cardiac events and improving health outcomes, AND the substantial room for improvement, with less than 30% of those eligible being referred and enrolled in a cardiac rehab program, the goal for cardiac rehab has been set at a participation rate of 70%. Achieving this 5-year goal would prevent 25,000 deaths and 180,000 hospitalizations annually.5
Finally, helping people practice healthy habits starts in the community, with good design, ready access, and peer group activities, and is reinforced by clinicians who equip and empower their patients to adopt heart-healthy behaviors.
Evidence has shown that high performing health care teams can reach these targets by excelling in the use of:
Care Teams, including pharmacists, nurses, community health workers, and cardiac rehab teams. The nation needs everyone working at the top of their license and abilities.
Technology, such as electronic health records that include clinical decision support, patient portals, e- and default referrals, registries, and algorithms to find gaps in care.
Processes that ensure quality care, such as treatment protocols; daily huddles of the medical team; scorecards that show performance status on the ABCS; proactive outreach to patients about their risks, such as uncontrolled high blood pressure; and finding patients with undiagnosed high blood pressure, high cholesterol, or tobacco use; and
Patient and family supports, such as training in self-measured blood pressure monitoring; problem-solving in medication adherence; counseling on nutrition, physical activity, tobacco cessation, and avoiding exposure to particulate matter (also known as particle pollution); and systematic referrals to community-based physical activity and cardiac rehab programs.
*Aspirin use when appropriate, BP control, Cholesterol management, Smoking cessation

9. Improving Outcomes for Priority Populations
Disparate outcome
Effective interventions
Well-positioned partners
Priority Population
Objectives
Strategies
Blacks/African Americans
Improving hypertension control
Implement tailored protocols
Problem-solve in med adherence
35-64 year olds
Improving HTN control and statin use
Decreasing physical inactivity
Increase access to and participation in community-based activity programs
People who have had a heart attack or stroke
Increasing cardiac rehab referral and participation
Avoiding exposure to particulate matter
Use opt-out referral and CR liaison visits at discharge; ensure timely enrollment post-discharge
Increase use of Air Quality Index tools
People with mental illness or substance abuse disorders
Reducing tobacco use
Integrate tobacco cessation into behavioral health treatment
Institute tobacco-free policy at mental health and substance use treatment facilities
Tailored quitline protocols
There are many populations that have higher rates of cardiovascular disease that can stem from higher rates of risk factors, such as high blood pressure and tobacco use (among others). This often leads to increased rates of death and disability in these populations.
Million Hearts® selected thse initial priority pops
Blacks/African Americans with HTN. Awareness and treatment of HTN have improved but control rates lag behind.
35- to 64-year-olds, among whom event rates are rising,
People who have had a heart attack or stroke, and
People with mental illness or substance abuse disorders who have high rates of tobacco use (also metabolic syndrome, overwt, physical inactivity)
It is important to note that these populations can overlap. Also, this list is not exhaustive.
Million Hearts® selected this starter set of national priority populations based on three factors:
Data that show a significant disparity in cardiovascular disease outcomes;
Effective or promising interventions that address the populations’ needs; and
Partners well positioned to implement the interventions and connect with those affected.
The hope is that listeners will join the initiative in addressing the needs of these priority populations or identify and address the needs of the priority populations they have identified in a similar way and that the listeners will also keep the Million Hearts® team apprised of their progress.

10. Use among Medicare Fee-for-Service Beneficiaries
~450,000 beneficiaries were eligible in 2013*
20% used CR at least once in 12 months
57% of CR users completed 25 or more sessions
Preliminary data analyses from 2013 illustrate the baseline context of cardiac rehabilitation (CR) eligibility and utilization among fee-for-service Medicare beneficiaries. Approximately 450,000 FFS beneficiaries had a qualifying condition in 2013 that would make them eligible for CR (these included having an acute myocardial infarction, coronary artery bypass surgery, current stable angina pectoris, heart valve repair/replacement, percutaneous transluminal coronary angioplasty or coronary stenting, or heart-lung transplant [heart failure became an eligible condition in 2014]). Of those, 20% used cardiac rehab at least once within 12 months of their qualifying condition eligibility. Among those who initiated CR, 57% completed 25 or more sessions, a clinically meaningful threshold that has been shown to be associated with reduced mortality.
*Does not include those with heart failure, a new indication for CR as of 2013 10

11. Cardiac Rehab Utilization Rates among Eligible Medicare Fee-for-service Beneficiaries by Age, Gender, Race/Ethnicity, 2013
Here, we present Medicare data showing variation in CR utilization that may help with targeting and outreach strategies. Looking at CR use by demographic subgroups, we see variation and potential disparities in utilization. In the next set of slides, we will walk through the information in this figure piece by piece. This figure displays, in orange, the proportion of eligible beneficiaries in 2013 that initiated CR as well as showing, in blue, the percentage of those beneficiaries who initiated CR and completed 25 or more sessions. Overall utilization is presented first on the x-axis, followed by utilization by age, gender, and race/ethnicity.
*Completed 25 or more CR sessions
Source: Centers for Medicare and Medicaid Services’ Chronic Conditions Data Warehouse

12. Cardiac Rehab Utilization Rates among Eligible Medicare Fee-for-service Beneficiaries by Age, Gender, Race/Ethnicity, 2013
Focusing first on CR initiation, we again see the overall proportion of eligible beneficiaries that initiated CR is 20%. Looking at utilization by subgroups, we see low utilization among beneficiaries that are younger, female, and non-white.
*Completed 25 or more CR sessions
Source: Centers for Medicare and Medicaid Services’ Chronic Conditions Data Warehouse

13. Cardiac Rehab Utilization Rates among Eligible Medicare Fee-for-service Beneficiaries by Age, Gender, Race/Ethnicity, 2013
Turning now to examine the percentage of beneficiaries who completed 25 or more CR sessions, we again see that the majority (57%) complete 25 or more sessions. Aside from the lower proportion of younger beneficiaries, completion rates across key subgroups are fairly similar. These results indicate that although there may be disparities in initiation of CR by demographic subgroups, there is less disparity in completion rates.
Overall, only 13.4% or 2 in every 15 fee-for-service Medicare beneficiaries who are eligible for CR service, initiate rehab and complete at least 25 sessions.
*Completed 25 or more CR sessions
Source: Centers for Medicare and Medicaid Services’ Chronic Conditions Data Warehouse

14. Cardiac Rehab Utilization Rates among Eligible Medicare Fee-for-Service Beneficiaries by Census Division, 2013
Looking at variation in CR initiation and completion by census division, we see additional information that could be used for targeting interventions and resources. Many census divisions that have low initiation rates have high completion rates. For example, [click] the middle and south Atlantic divisions only have 17-19% of beneficiaries initiating CR but among those who initiate, over 60% complete 25 or more sessions. Alternatively, [click] the West North Central division has high initiation rates (over 30%) but low completion rates (49%).
[click] Most notably, the East South Central and West South Central divisions, which traditionally are the regions in the United States that have the greatest burden of cardiovascular disease, have the lowest CR utilization rates.
*Completed 25 or more CR sessions
Source: Centers for Medicare and Medicaid Services’ Chronic Conditions Data Warehouse

15. Million Hearts® Cardiac Rehab Collaborative
Amer Assoc of Cardiac and Pulm Rehab
Amer Association of Nurse Practitioners
American Academy of Family Practice
American College of Cardiology
American College of Physicians
American College of Sports Medicine
American Council on Exercise
America’s Essential Hospitals
American Heart Association
American Hospital Association/HRET
Blue Cross Blue Shield Assoc
Christiana Care
Cleveland Clinic
Clinical Exercise Physiology Assoc
CR Participants & Caregivers
Emory University
George Washington University School of Public Health and Health Services
Heart Failure Society of America
HHQI
Hospital of the University of PA
Howard University
Johns Hopkins
Mended Hearts
MedStar Health System
National Medical Association
Ohio State University
PCORI
Preventive CV Nurses Assoc
Relevate Health Group
Rush University Medical Center
Seton Hall University
University Hospitals
UCLA
U of Pennsylvania
U of Pittsburg
U of Vermont Health Network
Vanderbilt University
Visiting Nurse Service of NY
WomenHeart
AHRQ, ASPE, CDC, CMS (MA, CMMI), GSA, NHLBI, NIA, OPM, VA. HHQI.

16. ….increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the U.S.

17. CR Collaborative 2018 Action Plan Objectives
Increase awareness of the value of CR among health systems, clinicians, patients and families, employers, payers
Increase use of best practices for referral, enrollment, and participation; address knowledge gaps.
Reduce disparities in CR referral, participation, and program staffing
Increase sustainability of CR programs through innovations in program design, delivery, and payment
Measure, monitor, and report progress toward the CRC aim

18. Cardiac Rehab: Saving Lives, Improving Health
What is it?
Comprehensive, team-delivered, outpatient program of up to 36 one-hour sessions over ~12 weeks, designed to:
Limit the effects of cardiac illness
Reduce the risk for sudden death or re-infarction
Control cardiac symptoms
Stabilize or reverse the atherosclerotic process
Enhance the psychosocial and vocational status of patients

19. Cardiac Rehab: Core Components
Patient Assessment
Nutrition Counseling
Lipid Management
Hypertension Management
Smoking Cessation
Weight Management
Diabetes Management
Psychosocial Management
Physical Activity Counseling
Exercise Training
Source: Balady et al, Circulation 2000;102:

20. Cardiac Rehab: Who Benefits?
There is strong evidence of benefit---and good insurance coverage---for cardiac rehabilitation
Those with a prior heart attack or stable angina
Systolic heart failure and EF < 35%
Coronary Stent or angioplasty
Coronary Bypass, valve, heart transplant surgery
**Peripheral arterial disease with claudication**

21. Cardiac Rehab: What is the Evidence?
Reduces
Death from all causes by 11-24%
Death from cardiac causes by 26-31%
Hospitalizations by 31%
Improves
Adherence to medications by 31%
Functional status, mood, and Quality of Life scores
More is Better
36 vs fewer sessions reduces risk of heart attack and death
25 sessions is generally considered a healthy “dose”

22. The Effectiveness of CR in Secondary Prevention
Improved disease-related symptoms
Definite
Improved exercise capacity, 10%-30%
Improved resting blood pressure
Anti-inflammatory effect
Probable
Improved blood triglyceride
Improved endothelial function
Improved high density lipoprotein
Probable (mild)
Improved skeletal muscle strength
Improved blood glucose
Improved skeletal muscle endurance
Reduction in body weight
Partially
Decreased risk all-cause mortality
Definite/Probable
Improved mood (depression/anxiety)
Decreased risk all-cause hospitalization
Progress in Cardiovascular Disease :53; , ,

23. System-level Barriers to CR Referral
Referrals are generally ≤30% of eligible patients
Referral barriers include:
Lack of awareness of the benefits
No clear, consistent signal to patients and families
CR program is not integrated into CV services
No automated electronic referral process
“Opt-in” hospital discharge orders

24. Patient-Level Barriers to Participation
Logistics
Transportation/parking
Convenient hours
Proximity of programs
Cost-sharing
Competing responsibilities
Cultural and language issues

25. First Actions for Hospitals
Establish CR as a hospital priority
Inform ALL staff of the value of CR
Advertise the service to eligible patients and their families
Track, report, and reward referral and participation rates
Institute “opt-out” referral of eligible patients
Identify qualifying billing codes
Work with IT team to embed referral system in EHR
Engage hospital staff
Identify and train staff liaisons
Analyze current CR program data and begin to tackle issues
Establish protocol for engaging other important team members

26. Actions for Hospitals
Facilitate scheduling 1st session at time of referral
Identify CR program most convenient for the patient
Establish referral process with local CR programs
Create and implement a protocol for scheduling the 1st session
Reach out and reward eligible and enrolled patients
Provide appointment cards
Send motivational letters from hospital or program leadership
Send text message reminders
Celebrate milestones to encourage completion of > 25 sessions

27. Actions for Hospitals Minimize obstacles for eligible patients
Establish convenient hours
Offer free parking or public transit vouchers
Diversify workforce
Make the program gender-specific where possible
Provide transparent insurance/cost-sharing information
Establish CR referral performance measure
Create a unique measure in EHR system
Identify and nurture community stakeholders that can support CR referral and participation

28. Care Utilization Costs by CR Participation in a Universal Health Care System
Costs per day in the 36 mos after referral to cardiac rehab in 4 matched groups. Alter et al., Mayo Clinic Proc. 2017;92:

29. Cardiac Rehab Referral after Cardiac Stent
60% referral rate
The HOSPITAL was the most important factor for predicting referral rate
Rates ranged from 0 to 100%
Aragam et al, J Am Coll Cardiol 2015 May 19; 65 (19): 2079

30. QI Activities and CR Attendance
Figure 1. Quality improvement activities and their effects on patient attendance at cardiac rehabilitation. Each point represents the average number of session per patients enrolling in cardiac rehabilitation for the given month. Point A represents a policy change toward maximizing the total number of sessions. Point B represents institution of the patient orientation video. Point C represents the institution of the motivational/incentive program. The comparative periods are shown visually. As seen, there is a significant positive trend in the average sessions per patient over time (r , P < .001).
Pack QR, et al., JCRP 2013;33:

31. Cardiac Rehab Patient Work Flow
Step 1:
Patient identified with a qualifying dx or procedure
Step 2:
Visit from CR liaison
Step 3:
Referral to CR program
Referral-Enrollment Transition
? Step 3a Home Care
Step 4:
Enrollment in CR
Step 5:
Participation in CR
Step 6:
Completion of CR

32. Step 3a: Cardiac Rehab in Home Care Setting
Recent evidence that incorporating CR into the home care setting is feasible and increases access to CR services
“Adapted” CR based on feedback from pts and caregivers
Patient Themes: awareness of heart disease, motivation and caregivers’ importance, barriers to attendance
Caregiver Themes: gaps in care transitions and educational needs
Source: Feinberg et al JCRP 2017; 37 :
Feinberg et al Geriatric Nursing xx 2017: 1-8 ( Article in Press)

33. NIH Funding Opportunity Announcements
Increasing Use of Cardiovascular and Pulmonary Rehabilitation in Traditional and Community Settings (R61/R33)
Open Date (Earliest Submission Date): Sept 19, 2017
Letter of Intent Due Date: Sept 19, 2017
Application Due Date: Oct 19, 2017 by 5:00PM ET
Earliest Start Date: Jul 2018
Tailoring Cardiac Rehabilitation to Enhance Participation of Older Adults (R01)
Open Date (Earliest Submission Date): Oct 8, 2017
Letter of Intent Due Date: Oct 8, 2017
Application Due Date: Nov 8, 2017 by 5:00PM ET

34. Home-Based Cardiac Rehabilitation
Bud Langham, PT, MBA
Chief Clinical Officer
Encompass Health – Home Health and Hospice Divisions

35. Questions about Home-Based Cardiac Rehab
Is it safe? Yes…
Is it effective? Yes…
Then why isn’t everyone doing it? +

36. Home-Based Cardiac Rehab Program
Referral - Care Transition
Medication Reconciliation and Education
Anatomy and Physiology 101
Nutrition
Activity Modification
Stress Management
Risk Factor Modification
Symptom Limited Exercise
ADLs and IADLs
Community Reintegration
Discharge Planning – Care Transition

37. Symptom Limited Exercise in the Home
Patient Goals
Assessment
Exercise Prescription ?
Outcome Measures
Precautions
Modes of Exercise

38. The Role of Technology Monitoring Tele-Rehab and Tele-Nursing
Wearables
Apps
What’s next…

39. Recommended Reading AACVPR.org ACSM.org
Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, Cowie A, Zawada A, Taylor RS. Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2017, Issue 6.
Encompass Health | Confidential information

41. Questions?

42. Cardiac Rehab Resources: Facility locations
AACVPR: by zip code or state
CDC: by state

43. Cardiac Rehab Resources: HHQI Cardiac Rehab Video Playlist
12 videos
Different sources
For patients and clinicians
Topics:
CR Stage definitions
What to expect with CR
Patient’s sharing their CR stories
4-11 minutes in length

44. Cardiac Rehab Resources: Tools

45. Cardiac Rehab Resources: HHCDR Measure
Beginning March 15th
HHQI Adaptation Measure #643:
Did the patient receive a referral to cardiac rehab? Yes or No

46. Continuing Education Free continuing education credits Requirements
1.75 Nursing CEs (ANCC)
1.0 PT CCUs (FSBPT)
Requirements
Watch this webinar (90 minutes)
Register for the corresponding course in HHQI University
Complete the evaluation (15 minutes)
Download & print your certificate
Contact with any questions.

47. Continuing Education Steps
Follow these steps to get your CE certificate:
Register/log in to HHQI University. You will be automatically redirected to the HHQI University website when you exit this webinar. If you think you might have already registered for an HHQI University account but cannot remember your username, please contact us at:

48. Continuing Education Steps
Click on the Cardiac Rehab Roundtable course in the Cardiovascular Health course catalog.
Click on Enroll under the icon.
Click on My Account to launch the course.
Click on the icon next to the course in the View column.
Click on the icon in the Action column next to Lesson 1.
Complete Cardiac Rehab Roundtable lesson that includes an evaluation
Will take about 15 minutes of extra work following the webinar
After completing the evaluation, you can print your certificate from the My Account area in HHQI University.
Click on My Account on the black menu bar.
Your certificate will be in the My Certificates area on the left side of the screen.

49. Questions?

50. HHQI@qualityinsights.org www.HomeHealthQuality.org
Thank You!
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD