Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health Settings: A Science

AHA Science Advisory

Increasing Referral and Participation Rates to OutpatientCardiac Rehabilitation: The Valuable Role of HealthcareProfessionals in the Inpatient and Home Health Settings

A Science Advisory From the American Heart Association

Endorsed by the Preventive Cardiovascular Nurses Association and the AmericanAssociation of Cardiovascular and Pulmonary Rehabilitation

Ross Arena, PhD, PT, FAHA, Chair; Mark Williams, PhD; Daniel E. Forman, MD;Lawrence P. Cahalin, PhD, PT, CCS; Lola Coke, PhD, RN, FAHA; Jonathan Myers, PhD, FAHA;

Larry Hamm, PhD; Penny Kris-Etherton, PhD, RD, FAHA; Reed Humphrey, PhD, PT;Vera Bittner, MD; Carl J. Lavie, MD; on behalf of the American Heart Association Exercise, Cardiac

Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, Council onEpidemiology and Prevention, and Council on Nutrition, Physical Activity and Metabolism

Cardiovascular disease (CVD) continues to be the leadingcause of morbidity and mortality in the United States and

worldwide.1 In fact, the prevalence of CVD is on the rise as afunction of increased longevity and the mounting effects ofcardiac risk factors that typically accumulate over a lifetime.Outpatient cardiac rehabilitation (CR) programs offer a cost-effective, multidisciplinary, comprehensive approach to addressthese risk factors and to restore individuals to their optimalphysiological, psychosocial, nutritional, and functional status.2–6

Thus, the benefits of CR extend well beyond the cardiovascularsystem, positively affecting an individual’s overall health status.These benefits may be particularly important to certain CVDcohorts such as elderly patients who are more likely to presentwith greater functional limitations and frailty. Additionally,outpatient CR has been shown to dramatically reduce morbidityand mortality by nearly 25% compared with usual care.7,8

Despite the clear benefits of formal, supervised outpatientCR and exercise training programs, as well as strides inautomatic referrals,9 current statistics continue to demonstrate

that referral and participation rates of eligible patients remainalarmingly low,10–13 with participation particularly poor inrural areas and in eligible patients who have lower socioeco-nomic status, limited education, advanced age, and/or femalesex.14,15 In addition, Gurewich et al16 reported several factorsthat are likely responsible for the poor referral rates tooutpatient CR, which included “the degree of automation andassertiveness in securing referrals, the level of integration ofCR within the hospital setting and physician community, therelationship to other CR facilities, and capacity constraints.”

Given the continually poor referral and participation rate inoutpatient CR despite increased efforts to reverse this trend,additional actions are required. This scientific advisory callson the inpatient and home healthcare teams (physicians,physician assistants, nurse practitioners, nurses, physicaltherapists [PTs], clinical exercise physiologists [CEPs], reg-istered dieticians, and CR team members) to implement acoordinated effort to promote outpatient CR to eligiblepatients and to facilitate referral and enrollment. Furthermore,

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outsiderelationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are requiredto complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on November 22, 2011. A copy ofthe document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchaseadditional reprints, call 843-216-2533 or e-mail [email protected].

The American Heart Association requests that this document be cited as follows: Arena R, Williams M, Forman DE, Cahalin LP, Coke L, Myers J,Hamm L, Kris-Etherton P, Humphrey R, Bittner V, Lavie CJ; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation andPrevention Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity andMetabolism. Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatientand home health settings: a science advisory from the American Heart Association. Circulation. 2012;125:●●●–●●●.

Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,visit http://my.americanheart.org/statements and select the “Policies and Development” link.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the expresspermission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.

(Circulation. 2012;125:00-00.)© 2012 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e318246b1e5

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this advisory recommends identifying an appropriately qual-ified healthcare professional to lead the inpatient multidisci-plinary team (Key Recommendations for further details).Whereas patient-centered care presumes that programs canand should be tailored to suit patient preferences, it implicitlyplaces an onus on the care-giving team to educate patientsand to promote therapies that will best address needs of agiven patient. The opportunity for the inpatient healthcareteam to increase participation rates in outpatient CR appearsto be underappreciated and therefore underused. Moreover,home health nursing and PT may also potentially play avaluable role in bridging the gap between acute care andoutpatient CR, especially for patients who are more disabledafter hospital discharge, thus improving the continuum ofcare and potentially increased referrals and ultimately partic-ipation rates. Therefore, a primary goal of this scientificadvisory is to better define the role of key healthcareprofessionals in both the inpatient and home health settings toultimately improve outpatient CR referrals and participation.

Defining Key Professions in the AcuteCare Setting

Multiple providers, with a broad range of expertise, are routinelyinvolved in the inpatient care of individuals suffering a cardiacevent. Similarly, a wide range of providers routinely attend topatients with a primary noncardiac issue but with managementalso affected by underlying cardiac disease. These health pro-viders have the opportunity to work together to promote outpa-tient CR as a unifying feature of care. Each profession may, inits own way, provide a valuable role in facilitating and encour-aging participation in outpatient CR after hospital discharge. It isessential, however, that strong oversight by someone familiarwith all aspects of the inpatient cardiac care process be identified(“inpatient CR director”) and empowered to direct the inpatientCR process, including those responsibilities outlined in the KeyRecommendations section. The following sections describeseveral key inpatient health professionals who can and shouldactively promote outpatient CR. Although a number of theresponsibilities described overlap and could be accomplished byone of several healthcare professions, each member of theinpatient CR team offers a unique skill set, warranting inclusionof all professions described in subsequent sections. Additionally,overlapping responsibilities among the health professionals in-volved should be viewed as positive, given that it will buildredundancy into the system and increase the likelihood ofeligible patients receiving key education and a referral tooutpatient CR. Moreover, consistent communication of theimportance of outpatient CR from multiple health professionalsis likely to increase the perceived value of this lifestyle inter-vention by a given patient. Unifying themes for all involvedinpatient health professions are an understanding of the impor-tance of CR to optimal recovery/outcomes in patients with CVD,a knowledge of all potential outpatient CR centers to which agiven patient could be referred within a particular geographicalregion, and development of a relationship with these outpatientCR centers to make the referral/enrollment process as efficientas possible.

NursingNurses in the inpatient setting can play a pivotal role ineducating patients about the value of outpatient CR after acardiac event/procedure. In numerous settings, nurses areintricately involved in discharge planning and, in theseinstances, can be instrumental in facilitating a referral tooutpatient CR. Independent predictors of participation inoutpatient CR include the patient being referred to outpatientCR while in the hospital and the patient perceiving the valueand need for CR.17 Both of these predictors could easily beaddressed by the nurse during inpatient hospitalization. In thepast, most inpatient healthcare facilities have had a phase ICR program, typically conducted by nurses and/or otherallied health professionals. Although many traditional phase ICR programs have been discontinued, nurses still play amajor role in providing inpatient programming. However, theresponsibility of securing the outpatient CR referral or pro-viding education on this valuable service can be ambiguous.If the inpatient nurse does not advocate for referral andencourage enrollment in outpatient CR, an important oppor-tunity is missed. Nurses must be cognizant that outpatient CRis an essential component of the recovery of all eligiblecardiac patients and that their encouragement and educationare essential first steps to facilitating participation in thisvaluable lifestyle intervention after hospital discharge.

Nurses assume responsibility for the day-to-day care of thepatient, including postoperative or postprocedural monitoringof vital signs, cardiac arrhythmias, and potential complica-tions, and are responsible for the administration of andeducation about cardiac medications and treatments. Duringthis 24-hour contact with the patient, nurses are in a positionto recognize key “teachable moments”18–20 and to discussoutpatient CR with patients who qualify for enrollment andtheir caregivers. Nurses should discuss the reasons for ob-taining a referral for outpatient CR and facilitate the process,the components of an outpatient CR program and how theypertain to the individual patient, the well-documented bene-fits of outpatient CR, how outpatient CR provides a safeenvironment for exercise, and how attending outpatient CRbuilds a network of resources for the future. The writinggroup acknowledges that these responsibilities are not spe-cific to the nursing profession and thus can be accomplishedby other appropriate healthcare providers. However, theincreased amount of contact time between the nurses and thepatient provides a unique opportunity to have an ongoing,in-depth discussion of the importance of outpatient CR.

Both inpatient nurses and nurse case managers often planand directly participate in the discharge of the patient’s postcar-diac event. They provide education, monitor patient data, andcontribute to the optimal discharge plan for the patient. In caseswhen home health care is warranted, the nurse case managertypically directly communicates with the home health agencythat provides home nursing follow-up when needed. A numberof patients who have had open heart surgery are provided aperiod of home health nursing and PT on discharge. Therefore,nurse case managers should take the initiative to reinforce theimportance of outpatient CR referral to the home health teamonce those services are complete. Home health professionalsshould also facilitate and encourage the patient to set up an

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outpatient CR appointment after recovery from the cardiacevent, as is discussed in subsequent sections.

Physical TherapyThe assessment of functional status and movement is a keyexamination from which PT treatment is prescribed and onwhich patient discharge from the hospital is based.21,22 In fact,the assessment of functional status in the inpatient setting byPT is 1 method by which many patients are deemed appro-priate to return home or to spend additional time at arehabilitation center.21–24 Although perhaps not widely appre-ciated and thus used in the current delivery model, participa-tion in inpatient PT may have the potential to dramaticallyimprove referral to outpatient CR.

Recent observations suggest that PT can be instrumental inproviding valuable guidance in the inpatient setting and thatadherence to recommendations may lower the risk of read-mission.25 This observation highlights the role that structuredassessments and sharing of patient information in the inpa-tient setting have in promoting favorable patient outcomesafter discharge. Recent longitudinal data reveal that outpa-tient CR referral and participation improve when this type ofstructured inpatient assessment exists for patients with anacute cardiac event or procedure.16,26 PT referral for inpatientintervention and discharge assessment provides an examina-tion of patient readiness for hospital discharge and entry intoan outpatient CR program. If an automatic referral forinpatient PT is not already in place, a strong case can be madefor the implementation of such a system given the likelihoodof a diminished functional capacity in the majority of cardiacpatients. This important step in the inpatient setting providesa robust referral base for outpatient CR26 and further ensuresthat CR is integrated within multiple disciplines workingtoward a common goal (ie, outpatient CR referral andparticipation). Of course, the inpatient PT in the cardiacsetting must be cognizant of this opportunity and the rolehe/she plays in promoting outpatient CR participation. Thiswriting group, particularly the members who are PTs, ac-knowledges that the proposed recommendations may repre-sent a paradigm shift for current PT practice in the inpatientcardiac setting. However, such a paradigm shift has thepotential to dramatically affect outpatient CR referral andparticipation in a positive manner.

In summary, PTs in the inpatient setting have the potentialto substantially improve outpatient CR referral given theirestablished presence in the inpatient cardiac setting and theirrole in assessing functional capacity and determining dischargestatus and placement on discharge (ie, home, subacute rehabil-itation facility).21–25 In addition to their primary role of assessingand improving functional status, the inpatient PT should provideeducation on the importance of outpatient CR participation to thepatient. The inpatient PT should embrace the role of advocate foroutpatient CR, educating patients on the value of participating inthis important lifestyle intervention and ensuring that a referralhas been secured on discharge.

Clinical Exercise PhysiologistsCEPs frequently are members of the multidisciplinary team inCR programs.27 Although more likely to be involved in the

outpatient program, the role of CEPs on the inpatient team isto provide expertise related to exercise prescriptions andtraining, physical activity recommendations, patient educa-tion, and exercise equipment. CEPs working in the inpatientsetting are likely to have regular contact with inpatients eitherthrough formal educational sessions or by meeting one-on-one with inpatients; thus, there are ample opportunities tocommunicate the clinical benefits of participating in outpa-tient CR to patients eligible for this intervention. Conse-quently, CEPs should be knowledgeable about the outpatientprogram model, referral process, hours of operation, andother program details that may be helpful to patients. Thisprovides a valuable link between the inpatient experience andthe outpatient program.

From an administrative perspective, if a CEP is employedby outpatient CR but also has responsibilities with an affili-ated inpatient program, he or she can assist with monitoringthe inpatient census and help to ensure that all eligible patientsreceive a referral to the outpatient program before discharge.This can be accomplished in a number of ways, includingcollecting paper referrals, verifying referrals in an electronicmedical record, attending staff meetings on the appropriateinpatient units, and attending discharge planning meetings.

Registered DietitiansGiven the poor nutritional patterns of a large percentage ofpatients suffering a cardiac event,28 medical nutrition therapyis an essential therapeutic component for the secondaryprevention of CVD.29 The habitual diet of many cardiacpatients falls far short of meeting the recommended dietarypattern for the secondary prevention of CVD.30 An extensivedatabase demonstrates the efficacy of a dietary intervention;however, sustained adherence to dietary advice is necessaryto achieve treatment goals.31 As reported by Artinian et al,32

the scientific literature describes impressive rates of initialbehavior changes after a cardiac event, but frequently they arenot translated to sustained behaviors.

Registered dietitians (RDs) are uniquely qualified to pro-vide medical nutrition therapy for cardiac patients by virtueof their training, expertise, and experience.33 The importanceof RDs being an integral member of the medical team isacknowledged by the Adult Treatment Panel III, whichrecommends that RD referral be considered at each lifestyletherapy visit.29 Moreover, Van Horn et al34 recommend thatpatients with hypercholesterolemia be referred to an RD formedical nutrition therapy. Thus, RDs in the inpatient settingare in the position to educate patients on the value ofoutpatient CR and to advocate for referral on discharge.Because follow-up is required for a sustained nutritionalbehavior change, it is uniquely important for inpatient RDs toadvocate for outpatient CR services. Thus, by doing their partin ensuring that eligible cardiac patients are referred andenrolled in outpatient CR, RDs can help patients achieve theirlong-term nutritional goals and facilitate their participation inother essential lifestyle interventions.

PhysiciansThe fundamental design of inpatient care for the cardiacpatient entails coordination between the physician and the

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above-described interdisciplinary team. Physicians involvedin the care of cardiac patients may come from numerousdisciplines (surgeons, interventionalists, primary cardiolo-gists, primary care physicians, hospitalists, etc) with differingperspectives and priorities. However, all physicians, regard-less of background and training, can share the common goalof promoting outpatient CR in eligible patients. Althoughday-to-day issues are addressed through a collaborative or-ganization, the physician has distinctive tasks: He/she plays aunique role in facilitating patient intakes and individualtreatment planning, performing patient assessments, and eval-uating medical safety. Likewise, the physician’s role andperspective are vital with respect to policies and procedures,and physicians must reinforce the value of outpatient CR andensure the referral of all eligible cardiac patients. Smith et al35

previously demonstrated that a physician-endorsed, auto-mated outpatient CR referral system results in higher rates ofintake and enrollment. Conversely, Grace et al36 demon-strated that physician uncertainty as to which member of thehealthcare team is responsible for securing an outpatient CRreferral negatively affects eventual enrollment. Therefore,inpatient physicians should ensure that an outpatient CRreferral system exists at their institution, identify the mem-ber(s) of the healthcare team responsible for securing thereferral, and express strong support for the process. Physi-cians should also express their strong support for outpatientCR to all of the aforementioned health professionals involvedin the care of cardiac patients and ensure that all members ofthe inpatient team discuss/endorse outpatient CR during theirrespective patient interactions. Moreover, in their own inter-actions with patients, their families, and other caregivers,physicians should convey the importance of outpatient CR totheir recovery and strongly encourage participation, which initself has been shown to improve enrollment.9 Finally, phy-sician assistants and nurse practitioners, who often work veryclosely with physicians, should adopt the same principles andrecommendations described in this section.

The Continuum of Care: Home HealthNursing and PT in the Immediate

Postdischarge PeriodAccording to recent estimates, roughly 7.6 million people inthe United States receive community-based care,37 with asignificant proportion receiving medical and therapeutic in-terventions at home. Moreover, the majority of home healthpatients are �65 years of age, a number that is expected toincrease as the population ages. Not unexpectedly, the mostfrequent diagnoses are distributed across clients with endo-crine and circulatory disorders. Nearly one third of homehealth patients present with diabetes mellitus and/or heartdisease, �40% with hypertension, and two thirds with dis-eases of the circulatory system.38

Poor referral and participation rates in outpatient CR pro-grams are well documented in patients being discharged fromthe inpatient setting.15 Presuming that these low referral andparticipation rates in outpatient CR programs can be applied tohome health patients, it is likely that a very low percentage of thepopulation managed at home are being provided optimal inter-ventions to help achieve the goals of preserving functional

independence or maximizing secondary prevention. The benefitsof outpatient CR are well established,39 so solidifying a conti-nuity of care from home health to an institution providingoutpatient CR is vitally important to reaching an ever-expandinggroup of patients in need of lifestyle modification.

Because home health is often provided by nurses and PTswho focus on this population, potential avenues exist toexpand the expertise of these practitioners in an effort to laythe foundation for eventual participation in outpatient CR,from both an educational and exercise training perspective, inthe home setting. All patients would benefit from risk factorreduction and education; thus, they should be woven into thehome health treatment plan. For the initial exercise trainingprogram, ECG monitoring via portable monitoring units orthrough telecommunication is feasible, and its use should bedictated by the clinical status of each individual patient. Evenso, effective monitoring of vital signs, symptoms, and toler-ance to exercise, combined with fundamental principles ofexercise prescription, will serve the majority of nurses andPTs well in their overall management of the home healthpatient with chronic disease who will eventually be amenableto outpatient CR. It should be noted that not all patientstreated in the home will become appropriate candidates foroutpatient CR, and the clinical judgment of the nurse and/orPT should assist the physician in determining the correcttherapeutic approach. However, referral and participation inoutpatient CR should be a goal for all eligible patients oncethey are no longer homebound.

Frequently, a time gap between acute care discharge andinitiation of outpatient CR occurs, creating a break in thecontinuum of care. For patients receiving home health care, thenurse and/or PT should reiterate the components, benefits, andsafety of outpatient CR to the patient that ideally were taught bythe inpatient healthcare team and assist in facilitating an appoint-ment, when appropriate, if one has yet to be made. Maintaininga continuum of care is an important concept that will improvepatient perception that outpatient CR is not just a choice but anexpectation for a complete recovery. Moreover, many barrierscontribute to why patients do not attend CR, including a lack ofaccess, transportation issues, perceived inconvenience, caringfor a spouse or others in the home, and financial need to returnto work.15,17,40,41 The home health nurse and/or PT can oftenprovide resources and/or strategies that may help the patientovercome these barriers. Finally, although the roles and respon-sibilities of the home health nurse and PT may differ, theunifying themes described previously for inpatient health pro-fessionals certainly apply to this setting as well.

A number of established outpatient CR programs incorpo-rate home health in their range of services.42 Training andsupport for home health nurses and PTs to effectively managetheir patients with appropriate CR strategies can be readilyprovided by outpatient CR program staff. Such collaborationis also likely to facilitate the transition from home health careto outpatient CR enrollment at the correct juncture of apatient’s recovery.

Key RecommendationsThe process of identifying key personnel to direct andimplement early inpatient CR, to educate about outpatient

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CR, and subsequently to facilitate patient entry into anoutpatient CR program is dependent on the resources of theinpatient setting, including administrative structure, availablepersonnel and their philosophical approach, and variouseconomic and regulatory considerations. Ideally, there shouldbe a smooth transition from inpatient to outpatient CRprogramming, but this is likely dependent on the initialadministrative designations of responsibilities. The Table

provides recommendations for inpatient CR programs thatwould facilitate referral and participation in outpatient CR.

At the outset of the planning process, it is important todevelop an inpatient CR structure that is led by an individual(inpatient CR director) who possesses a strong background inCVD prevention and rehabilitation, including exercise train-ing, CVD risk factor and behavioral modification, and pro-gram development. The interpersonal skills necessary todirect personnel from various health care disciplines, such asnursing, PT, CEP, and dietary, are also essential. In addition,the inpatient CR director must be an enthusiastic advocate foroutpatient CR in interactions with facility administrators andall other healthcare professionals involved. There are anumber of CR-related publications that the inpatient health-care team should thoroughly review. Perhaps two of the mostimportant documents that all healthcare team membersshould understand completely, particularly the inpatient CRdirector, are the “AACVPR/ACCF/AHA 2010 Update: Per-formance Measures on Cardiac Rehabilitation for Referral toCardiac Rehabilitation/Secondary Prevention Services: A Re-port of the American Association of Cardiovascular andPulmonary Rehabilitation and the American College of Car-diology Foundation/American Heart Association Task Forceon Performance Measures (Writing Committee to DevelopClinical Performance Measures for Cardiac Rehabilitation)”11

and the earlier 2007 publication.10 These publications advo-cate the use of a performance measure to assess outpatient CRreferral patterns from the inpatient setting, a practice thecurrent writing group strongly endorses. Other publicationsdetail the process for developing an automatic referral tooutpatient CR, which is also strongly endorsed by the currentwriting group.45 Finally, publications invaluable in develop-ing the policies and procedures for both inpatient and outpa-tient CR include the American Heart Association/AmericanAssociation of Cardiovascular and Pulmonary Rehabilitation(AACVPR) core components of cardiac rehabilitation46 andthe AACVPR core competencies for cardiac rehabilitationprofessionals.47 Finally, a clear understanding of reimburse-ment directives and regulations, at both the local and nationallevels, is also essential.

The individual overseeing inpatient CR should be identi-fied within the facility organizational chart and can beselected from medical staff or the staffs of other members ofthe healthcare team (eg, physicians, nursing, PT, CEP,dietary, or the existing outpatient CR program). The impactof credentialing requirements should also be considered atthis time. The inpatient CR director should have a strongrelationship with the medical staff, particularly cardiologists,internists, and family medicine practitioners. In addition, thedirector should have a defined level of autonomy to providefor program policies/procedures and structure, as well assupervision of all personnel contributing to the inpatient CRprogram or, at a minimum, during the provision of CRservices. Finally, the inpatient CR director should maintain anopen line of communication with home health professionalsto ensure that a continuum of care is maintained for thosepatients initially receiving care in the home. In this context,given the potentially significant role that primary care phy-sicians and their support staff (monitoring patient status,

Table. Recommendations for Inpatient Health Professionalsto Improve Referral to Outpatient Cardiac Rehabilitation*

Formulation of a multidisciplinary inpatient CR program to

Assess and prepare patients for discharge home and eventualparticipation in outpatient CR

Share relevant patient status and progress information during inpatientCR with all relevant inpatient healthcare professionals

Help to identify patients not ready for the initiation of exercise orparticipation in outpatient CR and patients at risk for functional decline,depression, anxiety, or other psychological or social problems that mayhinder acute, subacute, or long-term rehabilitation progress; considerreferral to home health therapy as a bridge to outpatient CR in thesepatients

Initiation of an automatic referral to appropriate inpatient healthprofessional(s) to assess the readiness of all patients with a cardiac eventfor discharge home and for participation in an outpatient CR program via

A functional assessment with a functional performance measure (ie,6MWT, TUG) to examine functional status directly and to enable theprescription of assistive devices and exercise as indicated, andperformance of a submaximal exercise test via low-level treadmill orcycle ergometry exercise in appropriate patients†

Use of generic (ie, SF-12 or SF-36) and/or specific (i.e., MLWHFQ, DukeActivity Scale) functional status questionnaires to examine perceivedfunctional status

Assessment of self-efficacy (ie, Cardiac Self-Efficacy Scale)

Nutritional assessment

Development and examination of evidence-based multidisciplinary models ofdischarge planning with a focus on

Educating all inpatient health professionals on the methods to implementthe above items

Educating all inpatient health professionals on the interpretation of theabove items and developing different methods to improve referral tooutpatient CR once acute, subacute, or long-term rehabilitationhospitalization is complete

Increasing referrals and participation in outpatient CR

Consider implementing quality indicators to objectively track outpatientCR referral performance

CR indicates cardiac rehabilitation; 6MWT, 6-minute walk test; TUG, timedup-and-go; SF-12, Medical Outcomes Short Form-12; SF-36, Medical Out-comes Short Form-36; and MLWHFQ, Minnesota Living With Heart FailureQuestionnaire.

*The functional assessment, submaximal exercise test, and inpatient CRprogram should use all methods outlined in the American Association ofCardiovascular and Pulmonary Rehabilitation cardiac rehabilitation guidelines,including monitoring of symptoms, vital signs, and ECG in appropriate patients,as well as American Association of Cardiovascular and Pulmonary Rehabilita-tion/American College of Cardiology/American Heart Association performancemeasures for cardiac rehabilitation.10,11,27

†The American Heart Association and American College of Cardiology havepreviously described patients who may be appropriate for low-level exercisetesting.39,43,44

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responding to home health professionals questions/concerns,titrating medications, etc) play in the care of patients in thehome health setting, it would be advantageous for theinpatient CR director to establish and maintain communica-tion with health professionals in this setting as well.

A positive relationship among the inpatient CR program,home health, and outpatient CR program is essential to theprocess of outpatient referral and participation and to long-termoutcomes. The process must be fluid and well understood by all,including administrators, physicians, program staff, patients, andtheir families. For patients, care must be taken to providestructured, culturally sensitive, health-literacy–appropriate, edu-cational sessions and materials on the benefits and importance ofoutpatient CR. Inpatient physicians should strongly supportefforts by the inpatient rehabilitation team to educate patientsand families about outpatient CR, thus facilitating referral.

Educating patients and families, securing referral, andultimately increasing participation in outpatients CR mightappear to be a relatively simple process for facilities that haveboth inpatient and outpatient CR available but surprisingly,even under these circumstances, can be challenging. This islikely to be even more cumbersome when patients firstreceive home health care and/or are referred to other centersfor outpatient CR within the same city, within a given state,or beyond. Tertiary or quaternary referral centers with largereferral regions may find this aspect particularly challengingand may choose to develop the inpatient/outpatient transi-tional process in stages, focusing first on within-institutionreferral and then on an outpatient CR referral network toaccommodate patients’ geographic preferences and needs.Beyond the inpatient center processes leading to within-institution CR participation, it is imperative that the directorof inpatient CR be familiar with the referral mechanisms andconsiderations for patient participation in outside centers,including and especially related to reimbursement and ongo-ing physician oversight of patient care. This can sometimesbe difficult when patients participate in centers withoutobvious ties to the inpatient-based physician. The inpatientCR director should initiate discussions with all referringphysicians on preferences for outpatient centers and thedesired mechanisms for ongoing patient follow-up. Superbcommunication skills and timely correspondence to outsidecenters are critical for success in this process. In instanceswhen there is an anticipated gap between inpatient dischargeand initiation of the outpatient CR program, a home healththerapy referral in the interim should be strongly considered.Therefore, the inpatient CR director should also be familiarwith processes associated with such referrals.

Future DirectionsDespite the documented benefits of outpatient CR and thefact that it is strongly supported in many national guidelines,studies continue to show that only a small percentage ofeligible patients are referred.46,48 Going forward, furtherefforts must be made to address the barriers to referral andparticipation in outpatient CR, including those from clinical,community, and research perspectives. The following futuredirections are proposed to address the lack of referral tooutpatient CR:

1. Educate providers, healthcare systems, patients, andtheir families about the benefits of outpatient CR. Ageneral lack of knowledge about the benefits of outpa-tient CR clearly exists among both patients and health-care providers. This is no doubt a major contributor toits persistent underutilization. Education on the benefitsof CR must include efforts to change the perception ofoutpatient CR as less important than pharmacological orinterventional therapy.

2. Reduce barriers to referral and participation in outpa-tient CR. The reasons for lack of referral are numerousand include not only lack of awareness by healthcareproviders of its benefits (both improvements in numer-ous health metrics and healthcare expenditures) but alsobarriers attributable to patients themselves (knowledgeof benefits, motivation to participate), health systembarriers (perception of its value, priority given to acutecare rather than secondary prevention), and communitybarriers (infrastructure, availability of programs, publicpolicy).49

3. Promote a better understanding of outpatient CR as acost-effective, multidisciplinary secondary preventiontreatment option and chronic disease management ser-vice. The perception that outpatient CR is an exercise-only, gym-based treatment contributes to the discour-agement of referral and participation for eligiblepatients. The typical patient referred to outpatient CRhas multiple subclinical and clinical diagnoses, yetmany rehabilitation programs do not get enough refer-rals to maintain financial viability. Thus, programs mustbe designed to incorporate patients with multiple diag-noses because this approach has been shown to becost-effective and to reduce personnel, program, andfacility redundancy.50 Programs should be structured toattract and manage this expanding group of patientswhile adhering to current treatment guidelines. A betterunderstanding of the spectrum of outpatient CR serviceswould enhance its status among policy makers andhealth care providers and would likely enhance re-sources and referrals directed to them.

4. Continue efforts to increase coverage and resources foroutpatient CR services. Healthcare referrals naturallyparallel reimbursement patterns, and the limited orabsent reimbursement for rehabilitation is an importantcontributor to low referral rates. Although there isinconsistency in reimbursement policies, lack of aware-ness among healthcare providers that Medicare andmany health insurance policies cover outpatient CRservices is another barrier to referral.

5. Increase awareness of outpatient CR performance mea-sures.11 Implementation of performance measures foroutpatient CR should be strongly considered. Thesemeasures help healthcare providers track referral rates,adopt tools to improve enrollment, and assess andimprove quality. System-based approaches such as au-tomatic ordering sets and discharge checklists for refer-ring eligible patients to a program have been shown toimprove referral rates.

6. Expand the spectrum of responsibilities of home healthnurses, PTs, and other allied healthcare providers toinclude home-based or community-based CR.

7. Continue innovative strategies to bring rehabilitation tomore patients. Another impediment to referral is lack ofaccessibility to formal programs. Telemedicine,

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Internet-based, home-based, and community programshave shown promise as alternative models for outpatientCR.51–54 In addition, women, the elderly, and patientswith comorbidities appear to be less likely to receive anoutpatient CR referral.15,55 Educating physicians andother healthcare professionals involved in patient carethat all eligible patients benefit from outpatient CR canbe an important step in broadening the referral base.

8. Continue research initiatives to fill gaps in CR litera-ture. Poor CR referral patterns are also likely attribut-able to the lack of randomized controlled trials thatinclude cohorts receiving modern therapy for CVD andcurrent and comprehensive CR cost-effectiveness anal-yses that include examination of the impact of patient(eg, single-vessel disease with preserved ventricularfunction versus multivessel disease with diminishedventricular function) and program (eg, program locationand commute distance [rural versus urban]) character-istics. These types of investigations, if they are properly

conducted and produce positive findings, would furtherbolster support for CR.6

ConclusionsCR and secondary preventive services have been well docu-mented to reduce morbidity and mortality. In addition, focusingresources toward lifestyle changes and the spectrum of othersecondary prevention therapies through multidisciplinary outpa-tient CR has been shown to improve risk factor management andto reduce costs. Despite the well-documented benefits, outpa-tient CR referral and participation rates remain disappointinglylow. Therefore, greater efforts must be made to reinforce theimportance of outpatient CR among healthcare systems, provid-ers, and the public and thus to increase referral rates. Althoughenhanced efforts by inpatient and home health professionals toensure outpatient CR endorsement and referral would not ame-liorate all issues surrounding poor participation, such an ap-proach is likely to be highly beneficial.

Disclosures

Writing Group Disclosures

Writing GroupMember Employment Research Grant

OtherResearchSupport

Speakers’Bureau/

HonorariaExpert

WitnessOwnership

Interest

Consultant/Advisory

Board Other

Ross Arena University of NewMexico Health

Sciences Center

None None None None None None None

Vera Bittner University of Alabamaat Birmingham

None None None None None None None

Lawrence P.Cahalin

NortheasternUniversity

None None None None None None None

Lola Coke Rush UniversityMedical Center

None None None None None None None

Daniel E. Forman Brigham & Women’sHospital

None None None None None None None

Larry Hamm George WashingtonUniversity

None None None None None None Director, Board ofDirectors ofAmerican

Association ofCardiovascular

PulmonaryRehabilitation*

Reed Humphrey University of Montana None None None None None None None

Penny Kris-Etherton Penn State University None None None None None None None

Carl J. Lavie Ochsner HealthSystems

None None None None None None None

Jonathan Myers VA Palo Alto HealthCare System

None None None None None None None

Mark Williams Creighton UniversitySchool of Medicine

Department of Healthand Human

Services*; NationalInstitute on Aging*;

NIH*

None None None None None None

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on theDisclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the personreceives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under thepreceding definition.

*Modest.

Arena et al Cardiac Rehabilitation Referral 7

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who.int/cardiovascular_diseases/en/. Accessed June 22, 2011.2. Papadakis S, Oldridge NB, Coyle D, Mayhew A, Reid RD, Beaton L,

Dafoe WA, Angus D. Economic evaluation of cardiac rehabilitation: asystematic review. Eur J Cardiovasc Prev Rehabil. 2005;12:513–520.

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9. Gravely-Witte S, Leung YW, Nariani R, Tamim H, Oh P, Chan VM,Grace SL. Effects of cardiac rehabilitation referral strategies on referraland enrollment rates. Nat Rev Cardiol. 2010;7:87–96.

10. Thomas RJ, King M, Lui K, Oldridge N, Pina IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation forreferral to and delivery of cardiac rehabilitation/secondary preventionservices. Circulation. 2007;116:1611–1642.

11. Thomas RJ, King M, Lui K, Oldridge N, Pina IL, Spertus J. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabili-tation for referral to cardiac rehabilitation/secondary prevention services:a report of the American Association of Cardiovascular and PulmonaryRehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures(Writing Committee to Develop Clinical Performance Measures forCardiac Rehabilitation). Circulation. 2010;122:1342–1350.

12. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB.Use of cardiac rehabilitation by Medicare beneficiaries after myocardialinfarction or coronary bypass surgery. Circulation. 2007;116:1653–1662.

13. Squires RW. Are cardiac rehabilitation programs underutilized bypatients with coronary heart disease? Nat Clin Pract Cardiovasc Med.2008;5:192–193.

14. Cortes O, Arthur HM. Determinants of referral to cardiac rehabilitationprograms in patients with coronary artery disease: a systematic review.Am Heart J. 2006;151:249–256.

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Reviewer Disclosures

Reviewer EmploymentResearch

Grant

OtherResearchSupport

Speakers’Bureau/

HonorariaExpert

WitnessOwnership

Interest

Consultant/Advisory

Board Other

Paul Chase Lebauer CardiovascularResearch Foundation

None None None None None None None

Veronique L.Roger

Mayo Clinic NHLBI† None None None None None None

Jane NelsonWorel

Meriter Medical Clinic None None None None None None None

This table represents the relationships of reviewer that may be perceived as actual or reasonably perceived conflicts of interest as reported on the DisclosureQuestionnaire ,which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or moreduring any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant”under the preceding definition.

†Significant.

8 Circulation March 13, 2012

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45. Fischer JP. Automatic referral to cardiac rehabilitation. J CardiovascNurs. 2008;23:474–479.

46. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM,Franklin B, Sanderson B, Southard D. Core components of cardiac reha-bilitation/secondary prevention programs: 2007 Update: A ScientificStatement From the American Heart Association Exercise, CardiacRehabilitation, and Prevention Committee, the Council on ClinicalCardiology; the Councils on Cardiovascular Nursing, Epidemiologyand Prevention, and Nutrition, Physical Activity, and Metabolism; andthe American Association of Cardiovascular and Pulmonary Rehabil-itation. Circulation. 2007;115:2675–2682.

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KEY WORDS: AHA Scientific Statements � rehabilitation

Arena et al Cardiac Rehabilitation Referral 9

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Myers, Larry Hamm, Penny Kris-Etherton, Reed Humphrey, Vera Bittner and Carl J. LavieRoss Arena, Mark Williams, Daniel E. Forman, Lawrence P. Cahalin, Lola Coke, Jonathan

Science Advisory From the American Heart AssociationValuable Role of Healthcare Professionals in the Inpatient and Home Health Settings: A Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2012 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation published online January 30, 2012;Circulation. 

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