Presentation on theme: "ANTONIO S. SIBULO Jr.MD,FPCC,FAsCC,FACC St.Luke’s Heart Institute"— Presentation transcript:
1 ANTONIO S. SIBULO Jr.MD,FPCC,FAsCC,FACC St.Luke’s Heart Institute THE FUNDAMENTALS OF SETTING UP A CARDIAC REHABILITATION PROGRAM. “ Do’s and Dont’s “ANTONIO S. SIBULO Jr.MD,FPCC,FAsCC,FACCSt.Luke’s Heart Institute
2 What is Cardiac Rehabilitation? Cardiac rehabilitation is a medically supervised program designed to optimize a cardiac patient’s physical, psychological, and social function.In addition, it aims to stabilize, slow or even reverse the progression of the underlying atherosclerotic processes, thereby reducing death and disability.
3 Why Run a Cardiac Rehabilitation Program? It is recognized as an integral component of the continuum of care for patients with cardiovascular disease. Its application is a Class I Recommendation in most contemporary cardiovascular clinical practice guidelines.J Am Coll Cardiol 2008;51:1619–31Participating in a cardiac rehabilitation (CR)program after a cardiac event yields well-established benefits in reducing cardiac and non-cardiac mortality as well as reducing morbidity and cardiac risk factors .Taylor AS et.al Am J med 2004;116:682-92
4 Why Run a Cardiac Rehabilitation Program? Because of this mounting evidence, a number of health care organizations have endorsed the use of CR services in persons with CVD by including provisions for CR in their practice guidelines and position papers.AACPVR/ACC/AHA 2007 Performance measures on Cardiac Rehabilitation for Referral to and Delivery of cardiac Rehabilitation/Secondary Prevention Services
5 What are the benefits of Cardiac Rehabilitation? The benefit is thought to be mediated by several factors, including:Benefits of exercise trainingPsychological benefits of group support and counselingImproved adherence to preventive therapiesImproved control of cardiovascular risk factors.
6 What are the demonstrated benefits of Cardiac Rehabilitation? A 20-30% reduction in all-cause mortality ratesDecreases mortality up to 5 years post participationReduced symptoms (angina, dyspnea, fatigue)Reduction in nonfatal recurrent myocardial over median follow-up of 12 monthsImproves adherence with preventive medicationsIncreased exercise performanceImproved lipid panel (total cholesterol, HDL, LDL ,and triglycerides)
7 What are the demonstrated benefits of Cardiac Rehabilitation? Increased knowledge about cardiac disease and its managementEnhanced ability to perform activities of daily livingImproved health-related quality of lifeImproved psychosocial symptoms (reversal of anxiety and depression, increased self-efficacy)Reduced hospitalizations and use of medical resourceReturn to work or leisure activities
8 Evidence Supporting Cardiac Rehabilitation Cardiac rehabilitation is now a Class I Indication in clinical guidelines for:Myocardial infarction (MI)Percutaneous Coronary Intervention (PCI)Coronary artery bypass grafting (CABG)AnginaHeart failureValvular heart diseasePeripheral arterial disease (PAD)
9 Group of Patients who will Benefit from CaRe Patients with a history of:Myocardial infarction (heart attack)Coronary artery bypass graft surgery (CABG)Current stable angina pectorisHeart valve repair or replacementPercutaneous transluminal coronary angioplasty (PTCA)/ or coronary stentingHeart or heart-lung transplantHeart Failure and those with ventricular assist devicesCoronary artery disease equivalents such as diabetes or peripheral artery diseasePatients with diabetesPeripheral arterial disease
10 Components of Cardiac Rehabilitation (4) Physician prescribed exerciseExercise training and other therapeutic exercise including aerobic and strength training.An Individualized Treatment Plan (ITP) is a required element that describes the individual’s diagnosis, the type, amount, frequency and duration of the items and services under the plan and the goals set for the individual under the plan. The plan is written, established, reviewed, and signed by a physician every 30 days.
11 Components of Cardiac Rehabilitation 2. Cardiac risk factor modificationIncludes education, counseling, and behavioral intervention; related to the individual’s care and tailored to the individual’s needs.It may include a combination of one or more of the following.Physical ActivityNutritionLipid managementBlood pressure managementSmoking cessationWeight managementDiabetes managementPsychosocial management
12 Components of Cardiac Rehabilitation 3. Psychosocial AssessmentEvaluation of the individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or cardiac condition.4. Outcomes AssessmentEvaluation of the patient’s progress as it relates to the individual’s rehabilitation goals and program.
13 Education, counselling and behavioral interventions
14 CONSIDER ORGANISATIONAL ASPECTS LOCATIONGym/Fitness CenterEQUIPMENTBicycle/Arm ErgometerTreadmillStepperRowing machineFree weights12 Lead ECG machineCardiac defibrillator/AEDExercise training for high-risk patients should be held in a hospital or venue with immediate access to full resuscitation services and a member of staff trained in advanced life support.
17 In setting up a care program- Do’s Promote your program through Publicity and AdvertisingIn your efforts, target your community at large. Be sure to include hospital administrators, physicians, coworkers, and current patients.Advertise your program through your in-house newsletters and bulletins.Arrange for interviews on radio or local news magazine shows to publicize your hospital’s program. Provide specific information on heart disease prevention and rehabilitation.Sponsor an educational program or seminar for health professionals. Make your special events fun and educational. Offer risk factor assessments, smoking cessation clinics, heart-healthy cooking classes, etc.
18 In setting up a care program- Do’s Individualize Evaluation and Goal development for every patientThe Staff should be committed to treating each patient as a unique individual with special needs and concerns.Ensure that systems are present to obtain the clinical informations so that the CaRe team can develop an appropriate patient-centered treatment plan that prioritize goals and outlines intervention strategies for exercise training, tactics to reduce cardiovascular disease risk and a follow-up plan that reflects progress towards goals.
19 In setting up a care program- Do’s Individualize Evaluation and Goal development for every patientResults of recent cardiac tests including TET,ECG,2DEStatus of cardiopulmonary ,orthopedic andneuromuscular system, cognitive functionDetailed review of CV risk factorsComplete list of medicationsPatient specific symptoms of angina or its equivalentsComorbid conditions with attention to their impacton exercise, adherence and disease progressionPertinent psychosocial and occupational history
20 In setting up a care program- Do’s Device Strategies to improve ReferralsClinicians should consider instituting processes that encourage referral of appropriate patients to CARE. In addition, it is important that referring healthcare practitioners and CARE teams communicate in ways that promote patient participationImplementation of standing referral orders to CARE based on eligible diagnoses supported by clinician guidelines. These “systematic” strategies are implemented manually or may be autumativally using discharge order sets in medical records.
21 In setting up a care program- Do’s Device Strategies to improve Referrals“liaison” strategies- in which a healthcare provider or peer mentor speaks to the patient at the bedside about CARE and facilitates referral while permitting discussion of the nature and merits of such programs and potential barriers to participation.Dissemination of patient education materials or motivational letters both designed to augment CARE utilization.Grace SL et al. Referral to and discharge from cardiac rehabilitation: Key informant views on continuity of care. Presented at the University Health Network Annual Research Day. Toronto, ON:2003.
22 In setting up a care program- Do’s Device Strategies to improve Referrals“Automatic“- in which the patient would be sent a letter detailing the clinic appointmentLiaison- when a healthcare professional would explain the benefits of the program to the patient while they were still in the hospital Combination of the two previous approaches.Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization rates. Arch Intern Med 2011; 171:
23 In setting up a care program - Do’s Address the Common Barriers to Cardiac Rehab ParticipationAge- younger patients more likely to participateGender difference- female patient less likely to participateFinancialLack of Patient MotivationPatient work and time conflictsLack of Physician support and referralDistance and transportation
24 In setting up a care program - Do’s Incorporate CARE Program to packages of CV care to ensure UtilizationThe program director should address issues pertaining to reimbursement of servicesCurrently, where issues regarding insurance coverage and copayment of services by the patient may hinder referral to cardiac rehab, efforts should be made to incorporate these programs in CV care payment packages to ensure its utilization.
25 In setting up a care program - Do’s Incorporate CaRe Program to packages of CV care to ensure UtilizationPhase ofCardiac RehabNumber of inclusive sessions(8,12,24,36..)Gross amountDiscounted AmountPhase IPhaseIIPhase IIIPhase IVItems inluded in package:Cardiac rehab serviceStress TestDoctor's FeeDiet Counselling feeTelemetry monitoring
26 In setting up a care program - Do’s Promote Physician and Patient Education with emphasis on Lifestyle changes as an intergral part of secondary prevention strategiesRehabilitation phase includes patient education sessions regarding lifestyle change, diet and detrimental habits, such as smoking.Apply specific educational strategies to achieve behavioral change that will address cardiac risk factors and optimize compliance to medication and exercise training.
27 In setting up a care program - Don'ts Don't forget the following:Close interaction with the patient's primary care provider, cardiologist and cardiovascular surgeon who cares for the the patient's overall cardiovascular health.Identify high risk patients for closer monitoring and those who need further cardiac work-upMonitor patient progress toward achieving goals and ensure that patient and program outcomes are consistent with current clinical practice guidelinesMake CARE sessions interesting and promote patient interaction to encourage group support