Million Hearts Cardiac Rehabilitation Change Package
A MILLION HEARTS ACTION GUIDECardiacRehabilitationCHANGE PACKAGE
This Cardiac Rehabilitation Change Package was completed by the Centers for Disease Control and Prevention (CDC) incollaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) with the purpose ofhelping cardiac rehabilitation programs, hospital quality improvement teams, and public health professionals who partner withthese groups to implement systems and strategies that improve care for patients who are eligible for cardiac rehabilitation.AACVPR is a multidisciplinary professional association comprised of health professionals who serve in the field of cardiac andpulmonary rehabilitation.AuthorsThis document was conceptualized and authored by: Hilary K. Wall, MPH,1 Haley Stolp, MPH (IHRC, Inc.), Briana Lucido, MPH,CHES,1 and Kaitlin Graff, MSW, MPH.1ContributorsThe following individuals contributed subject matter expertise, identified tools and resources, and reviewed the document: JanetWright, MD, FACC,1 Todd M. Brown, MD, MSPH, FACC, FAACVPR (University of Alabama at Birmingham),2 Tracy Herrewig, MS, RCEP,FAACVPR (Ascension Mercy Hospital),3 Steven J. Keteyian, PhD, FAACVPR (Henry Ford Health System),2 Amy Knight, PhD (Universityof Alabama at Birmingham),2 Karen Lui, RN, MS, MAACVPR (GRQ, LLC),2 Ana Mola, PhD, RN, ANP-BC, MAACVPR (NYU LangoneHealth),2 Randal Thomas, MD, MS, MAACVPR, FACC, FAHA (Mayo Clinic),2 Kathleen Traynor, RN, MS, FAACVPR (MassachusettsGeneral Hospital),2 Janice Anderson, RN, BSN, CCRP (Christiana Care Health System), Tamara Garwick, MA, RCEP, FAACVPR (MountCarmel Health System), and Shawn Leth, MEd, CEP (Mayo Clinic).ReviewersThe following individuals provided review and feedback on the document: Mary G. George, MD, MSPH, FACS, FAHA,1 Judy Hannan,RN, MPH,1 Salvatore Lucido, JD, MPA,1 Betsy Thompson, MD, MSPH, DrPH,1 Barbara Courtney, MS, RCEP, FAACVPR (AdventistHealthCare), Kathleen Tong, MD (University of California, Davis), and Mark Williams, PhD (Creighton University School of Medicine).Graphic Design and Editorial AssistanceGraphic and HTML design support was provided by: Shelby Barnes, MPH, CHES,1 Booker Daniels, MPH,1 Susan Davis (NorthropGrumman Corporation), and Jessica Spraggins, MPH.1 Editorial support was provided by: Jena Eberly Stack, MEd, PMP,3 MeganCohen, MPA, CAE,3 and Hannah Muerhoff, BA.3We would like to extend special thanks to the following organizations for their willingness to share tools and resources to improvecardiac rehabilitation referral, enrollment, and participation as further denoted within the Cardiac Rehabilitation Change Package:Baystate Medical Center, Springfield, MABeth Israel Deaconess Hospital–Milton, Milton, MAChristiana Care Health System, Wilmington, DEEmory Healthcare, Atlanta, GAGenesis Hospital, Zanesville, OHHenry Ford Health System, Detroit, MILake Regional Health System, Osage Beach, MOMassachusetts General Hospital, Boston, MAMemorial Hospital of Carbondale, Carbondale, ILMiriam Hospital, Providence, RIMount Carmel Health System, Mount Carmel, OHNYU Langone Health, New York, NYPenn Medicine, Philadelphia, PARochester Regional Health, Rochester, NYSouthwest Florida Heart Group, Fort Myers, FLUniversity of Alabama at Birmingham, Birmingham, ALUniversity of Vermont Medical Center, Burlington, VTFor More InformationHilary K. Wall, MPHDivision for Heart Disease and Stroke Prevention, Centers for Disease Control and Preventionhwall@cdc.govSuggested CitationCenters for Disease Control and Prevention. Cardiac Rehabilitation Change Package. Atlanta, GA: Centers for Disease Control andPrevention, US Dept of Health and Human Services; 2018.Centers for Disease Control and PreventionAmerican Association of Cardiovascular and Pulmonary Rehabilitation3American Association of Cardiovascular and Pulmonary Rehabilitation Headquarters12
ContentsWhat Is Cardiac Rehabilitation?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1What Can Be Done?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2What Is the Cardiac Rehabilitation Change Package?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Figure 1. Cardiac Rehabilitation Change Package Focus Areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2How Can I Use the Cardiac Rehabilitation Change Package?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Figure 2. Institute for Healthcare Improvement Model for Improvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3How Do I Measure Quality Improvement Efforts?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Figure 3. Example of a Run Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Change Concepts, Change Ideas, and Tools and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Table 1. Systems Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Table 2. Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Table 3. Enrollment and Participation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Table 4. Adherence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Appendix A: Additional Quality Improvement Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Website addresses of nonfederal organizations are provided solely as a service to readers. Provision of an address does notconstitute an endorsement for this organization by CDC or the federal government, and none should be inferred. CDC is notresponsible for the content of other organizations’ webpages.
CHANGE PACK AGE 1What Is Cardiac Rehabilitation?Cardiac rehabilitation (CR) is a comprehensivesecondary prevention program designed toimprove cardiovascular health following acardiac-related event or procedure. While thereare some instances of inpatient (Phase 1) CR,the vast majority of CR is delivered in anoutpatient (Phase 2) setting and, therefore, isthe focus of this publication. An optimal CRexperience consists of 36 one-hour sessionsthat include team-based, supervised exercisetraining, education and skills development forheart-healthy living, and counseling on stressand other psychosocial factors.1Strong evidence shows that CR programs canbenefit individuals who have: Had a heart attack.2 Chronic stable angina.3 Received a coronary angioplasty or stent.4 Chronic heart failure.5 Undergone coronary artery bypass surgery,heart valve replacement or repair, or a heart orheart-lung transplant.6,7Many insurance companies cover CR for theconditions listed above,* but it is necessaryto review each patient’s individual insurancebenefits for CR.Participation in a CR program can reducethe risk of death from any cause8,9 and fromcardiac causes,9,10 as well as decrease hospitalreadmissions.9,11 CR participation also improvesfunctional status,11 quality of life,9–11 and mood.12Participation in a CR program can reduce the risk of deathfrom any cause and from cardiac causes, as well as decreasehospital readmissions. CR participation also improvesfunctional status, quality of life, and mood.Despite these benefits, enrollment in CR remainslow, ranging from 10% to 34% in nationalanalyses,13–15 with strong state-by-state geographicvariations14,16 and differences by cardiacdiagnosis.14,15,17 Barriers to program enrollmentare many, occurring at the health system, policy,program, and patient levels. For example,although CR services are widely covered bypublic and private health insurance plans,co-payments per session represent a financialobstacle for many patients.Million Hearts , a national initiative co-led bythe Centers for Disease Control and Prevention(CDC) and the Centers for Medicare & MedicaidServices (CMS) with the goal of preventing onemillion acute cardiovascular events by 2022, hasworked with CR professionals to set a nationalgoal of 70% participation in CR for eligiblepatients.1 Improving awareness about the valueof CR, increasing referral of eligible patients,and reducing system and patient barriers toparticipation are all critical steps in improving thereferral, enrollment, and participation rates in CRprograms. More importantly, effective remedieshave been identified but are not being widelyand systematically implemented.* In addition, individuals with peripheral arterial disease (PAD) and intermittent claudication benefit from supervised exercise therapy (SET).Although SET for PAD is a separate and distinct service from CR, CR programs are an ideal setting for the delivery of SET.
2 CARDIAC REHABILITATIONWhat Can Be Done?Because CR is so underutilized, program staff,other health care professionals, and othersinterested in improving rates of referral,enrollment, and/or participation have a uniqueopportunity to be change agents for theirinstitutions. Improvement in CR utilization anddelivery will require one or more championsto identify needed changes, find solutions, andmeasure and share progress. Multiple championsare likely needed since referral, enrollment, andparticipation often involve many: Processes (e.g., incorporating referral to CRinto discharge order sets, integrating healthinformation technology, changing workflows). Disciplines (e.g., cardiology, hospitalmedicine, rehabilitation). Professionals (e.g., physicians, nurses, exercisephysiologists, administrators). Locations (e.g., inpatient units, CR programs,physician offices).What Is the Cardiac RehabilitationChange Package?The Cardiac Rehabilitation Change Package(CRCP) presents a listing of process improvementsthat CR champions can implement as theyseek optimal CR utilization. It is composed ofchange concepts, change ideas, and tools andresources. Change concepts, sometimes calledkey drivers, are general notions that are usefulin the development of more specific ideas forchanges that lead to improvement. Change ideasare actionable, specific ideas or strategies forchanging a process. Change ideas can be rapidlytested on a small scale to determine whether theyresult in improvements in the local environment.With each change idea the CRCP lists one or moreevidence- or practice-based tools and resourcesthat can be adapted by or adopted in a healthcare setting to improve CR utilization.The purpose of the CRCP is to help qualityimprovement (QI) teams from hospitals and CRprograms put systems and strategies in placethat target improved care for more of the eligiblepatients. The CRCP is broken down into four mainfocus areas (Figure 1):Figure 1. Cardiac Rehabilitation Change Package Focus Areas
CHANGE PACK AGE 3How Can I Use the CardiacRehabilitation Change Package?The CRCP is meant to serve as a menu ofoptions from which QI teams can select specificinterventions to improve CR utilization. We donot recommend that any teams attempt toimplement all of the interventions at once, nor isit likely that all interventions will be applicable toyour clinical setting.Start by bringing together a team of CRprofessionals, physicians, administrators, andother relevant stakeholders to discuss theaspects of CR utilization that are most in needof improvement. The team can then selectcorresponding interventions from the CRCP thatbest address those issues.Figure 2 depicts the Institute for HealthcareImprovement’s (IHI) Model for Improvement.18The Model for Improvement suggests first posingthree questions:1. What are we trying to accomplish?2. How will we know that a change isan improvement?3. What changes can we make that will resultin improvement?The answers to these questions will point you toyour QI objectives and related metrics. You canchoose strategies from the many listed in thisCRCP that align with your objectives and havebeen shown to result in improvement.Read through Tables 1–4 for a list of changeconcepts and ideas that hospitals andFigure 2. Institute for HealthcareImprovement Model for Improvement
4 CARDIAC REHABILITATIONCR programs can implement to improve CRutilization for their patient population. Eachchange concept and idea is paired with toolsand resources suggested by experts in thefield who have successfully used them. TheAcknowledgments and Contributors section listscontent contributors. Systems Change (Table 1) offers waysto establish foundations for effective CRutilization efforts and is likely the best place onwhich to focus initial QI efforts. These includeidentifying a champion to provide leadershipon focused QI efforts and making CR utilizationa priority. Referrals (Table 2) provides approaches aimedat bolstering CR referral. These include usingstandardized processes, electronic referrals,and health system data to drive improvement. Enrollment and Participation (Table 3)lists strategies that health systems can useto encourage enrollment and participationin CR. These include various modes ofpatient education and engagement anddifferent ways in which CR programs can bemodified to better accommodate patientneeds and preferences. Adherence (Table 4) strategies are aboutunderstanding patient characteristics that arepredictive of program drop-out and deployingstrategies to encourage adherence.2) Case studies—detailed examinations of howa specific cardiac rehabilitation program wasable to make a given change; they includemotivation for program changes, timeline,staffing, and facilitators and barriers.3) Program-specific tools—tangible resourcesthat have been implemented by CR programsor researchers and can be adopted as is oradapted to meet other programs’ needs.4) Organization-specific tools—resources fromclinical and public health organizations thatsupport cardiac rehabilitation.The tools contained in the CRCP have beenused in the field over the past several yearsto systematize and improve CR utilization.Consequently, some clinical details in thetools may reflect treatment and managementdecisions that do not apply to or differ from yoursetting. However, these tools can be adaptedby filtering in the evidence, practices, andcharacteristics that are unique to your patientpopulation. Because the science behind CRutilization is ever-changing, the CRCP will beperiodically updated.Once you have selected a change idea toimplement, work through a Plan-Do-Study-Act(PDSA) cycle with a small number of patients(i.e., a “small test of change”) to test the changeidea in your clinical setting.There are four types of tools showcased inthe CRCP:How Do I Measure QualityImprovement Efforts?1) American Association of Cardiovascular andPulmonary Rehabilitation (AACVPR) CardiacRehabilitation Systems Change, Referral,Enrollment, or Adherence Strategies—highlevel issue summaries with concise guidance toaid implementation of programmatic strategies.It is essential to monitor and measure QIefforts—both outcomes and processes. Overalloutcomes such as improved CR enrollment ratesor the percentage of patients who improvetheir functional capacity by 40% or more areimportant to measure, but it is also important
CHANGE PACK AGE 5to monitor process measures, such as thepercentage of eligible patients who are visited bya CR liaison while in the hospital. This type of datacan provide much-needed feedback on whetheror not the interventions you are using are beingsuccessfully carried out. Begin by collectingbaseline data on a process that you are interestedin improving. Then test your “change ideas” on asmaller scale using a small number of patients,and discuss with clinical staf any identifedpotential barriers to implementation. These smalltests of change can be used to assess the successof implementing the intervention and allow stafto make needed refnements prior to scaling upthe project to a larger level.One very helpful tool for displaying andmonitoring eforts over time is a run chart.A run chart is a graph that displays performanceon a given process or outcome longitudinally.It can be useful to chart performance over timeto concretely show decision makers and otherstakeholders why recommended changes areneeded. You can then document when specifcchanges were made to show the impact thatimplemented changes yielded on performance(Figure 3). See Appendix A for additional QI toolsand resources.Figure 3. Example of a Run ChartPercentage of Eligible Patients Referred to Cardiac Rehabilitation, Nowhere General Hospital, January - October 2017
6 CARDIAC REHABILITATIONChange Concepts, Change Ideas, and Tools and ResourcesBold font indicates CR programs that contributed content to Tables 1–4.Table 1. Cardiac Rehabilitation Change Package—Systems ChangeChange ConceptMake CR a HealthSystem PriorityChange IdeasTools and ResourcesEstablish a hospitalchampion, such as aquality of care leader ora CR administrator Lake Regional Health System—Cardiopulmonary Rehabilitation:Presentation for Board of Trustees Liverpool Hospital—Clinical Champions PowerPoint AACVPR—Crucial Conversations with Medical Providers & HospitalAdministrators About Cardiac Rehabilitation Services DeliveringValue Based Care Million Hearts —Getting to 70% Cardiac Rehabilitation Participation:Action Steps for HospitalsEngage the care team inCR and ensure their buy-inin CR AACVPR—Crucial Conversations with Medical Providers & HospitalAdministrators About Cardiac Rehabilitation Services DeliveringValue Based Care Lake Regional Health System—Cardiopulmonary Rehabilitation:Update to Department Managers Million Hearts —Cardiac Rehabilitation Infographic 2018 ACC/AHA Clinical Performance and Quality Measure for CardiacRehabilitation. Thomas RJ, et al. 2018.19Use CR referral, enrollment, AACVPR Cardiac Rehabilitation Systems Change Strategy—Using Cardiac Rehabilitation Referral Performance Measures in aand participation as qualityQuality Improvement Systemof care indicators AACVPR—Sample Performance Measures Letter for Physicians andProviders
CHANGE PACK AGE 7Table 2. Cardiac Rehabilitation Change Package—ReferralsChange ConceptsIncorporateReferral to CRinto HospitalStandardizedProcesses ofCare for EligiblePatientsChange IdeasTools and ResourcesInclude referral to CR inorder sets for appropriatepatients; incorporate intoEHR as appropriate Henry Ford Health System—EMR Discharge Order Set, “Opt Out”Cardiac Rehabilitation Referral Screenshot Template AMI Orders. Pages 24B–25B, Montoye CK, et al., 2005.20Include referral to CR indischarge checklists forappropriate patients;incorporate into EHRas appropriate Multidisciplinary Cardiac Discharge Checklist/Instructions. Page 1409,Thomas RJ, et al., 2007.21Include referral to CRin appropriate patientdischa
change concepts, change ideas, and tools and resources. Change concepts, sometimes called key drivers, are general notions that are useful in the development of more specific ideas for changes that lead to improvement. Change ideas are actionable, specific ideas or strategies for changing a process. Change ideas can be rapidly
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