11 PROGRAM MODELS FOR CARDIAC

REHABILITATION

PROF. DR. NABILA NAJAM

Director
IPM&R, DUHS
KEY POINTS

• Cardiac rehabilitation programs must be well integrated into the

cardiovascular care continuum.

• Cardiac rehabilitation programs must be tailored to meet

individual patient needs and promote positive, patient-centered
strategies for health behavior intervention.

• Referral to cardiac rehabilitation programs is best accomplished

by automotive routes of referral integrated into standard care
paths or care maps.
• Cardiac rehabilitation programs comprise a comprehensive range
of core components including patient assessment, risk
stratification, health behavior intervention, risk factor counseling,
vocational counselling, exercise training, patient education, and
the continuous assessment of performance measures.

• Service delivery models within cardiac rehabilitation include

inpatient, outpatient, facility-based, home-based and alternation,
such as internet-based programs for patients in remote areas or
areas where cardiac rehabilitation services are not available.
• Utilizing institution-based exercise, home-based exercise or a
combination of both, depending upon individual patient needs
and program resources.

• The design of program models should reflect the content of

evidence-informed clinical practice guidelines.
TYPES OF CARDIAC REHABILITATION REFERRAL
AND HOW THEY INFLUENCE UTILIZATION RATES

• Referral to CR needs to be an active process making use of clear

endorsements and motivational messaging from all key
stakeholders (all healthcare professionals and administrators)
that encourages and facilitates patient participation.

• An automated referral process from acute care to CR significantly

increases referrals and enrollment.
CARDIAC REHABILITATION- CORE COMPONENTS

• Cardiac rehabilitation programs are multifaceted,

multidisciplinary, interdisciplinary, and transdisciplinary patient
care environments.

• Cardiac rehabilitation programs include a comprehensive range of

core components addressing patient assessment, risk
stratification, health behavior interventions, risk factor
modification, exercise training, patient education, and
performance measures.
THE AACVPR, ACC

And AHA also developed and published a consensus statement for

CR performance measures to further build upon the core
components guideline and provide an evaluative framework for
programs (Thomas et al., 20017).

This document provided a list of performance measures and

suggested tools.
With respect to CR referrals, the following suggestions were put
forward:

• All hospitalized patients with a qualifying cardiovascular event

should be (automatically)

• referred to an early outpatient CR program prior to discharge.

• All outpatients with an appropriate cardiovascular diagnosis

within the past year who have not participated in CR should also
be referred for cardiac rehabilitation.
Structure-based And Process-based Issues
The performance measures for the delivery of CR services
addressed both structure-based and process-based issues:

• Structure of the CR program to support safety:

1. A medical director is responsible for the programs.

2. An emergency plan is in place with appropriate equipment and
staff available during patient care hours.
• Processes around patient assessment and documentation of

1. Risk for adverse events during exercise:

2. Changes in symptoms:
3. Modifiable risk factors and risk reduction intervention;
4. A coordinated plan of care with other health providers;
• Processes around monitoring of programs effective through
ongoing analysis of aggregate date including;

1. Referral and enrolment;

2. A plan to assess completion of CR;
3. Evolution of patient outcomes at comes at completion of programs;
4. Selection of program;
5. Selection of program performance indicators;
6. Quality imprudent strategies.
UPDATED CORE COMPONENTS OF CARDIAC
REHABILITATION.

• Core Component Component Elements

• Systematic patient referral processes Automated referral

History and physical assessment 

• . Risk stratification
• . Exercise stress testing
• . Risk factor assessment
• Patient Assessments  . Psychosocial assessment
. Nutritional counseling
. Nutritional assessment
. Lipid management .
. Hypertension management
• Psychosocial management -Physical activity counselling

• Health behavior interventions --

and risk . Smoking cessation
factor modification . Weight management
. Diabetes management
. Adherence to appropriate pharmacotherapy
• Adaptations of program models to improve accessibility
especially for underserviced Populations -

1. Home-based exercise with web-based exercise

2. Home-based exercise, program supervised
3. Hybrid programs, both home and program based exercise
Development of self-management techniques based around individualized assessme
problem-solving. Goal-setting and following up

• . Problem-solving. Patients should learn how to define their

disease-related problems and how to generate practical solution to
daily problem faced as results of chronic illness.

• . Decision-making. Cardiac rehabilitation counselors should

assist patients in acquiring the necessary, health-related
information sufficient to enable effective decision-making an
about health-related information and changes in their disease
condition.
• . Resource utilization. Patients should be assisted in finding
and utilizing multiple resources, many of which may be
commonplace or community-based

• . Partnership formation. Patients should learn how to form

productive partnership with health with health care providers
such as physicians, nurses and cardiac rehabilitation condition
while facility informed decisions regarding their disease
treatment.
• Action planning. It is vitally important for patients themselves
to take action in solution implementation and the development
self-efficacy. This skill is similar to the SMART (Specific,
Measurable, Attainable, Realistic and Time-defined) goal-setting
plan.

• Self-tailoring. Patients should be encouraged to self-tailor

health-enhancing programmes or activities such as exercise or
dietary change, based upon, based upon the previously defined
Exercise training

• . Aerobic training
• . Strength (resistance) training
• . Flexibility training
Leisure time activities

• . Daily, moderate physical exertion in sustainable and enjoyable

activities
• . Step counting with pedometers
Outcomes assessment programs
• Educational outcomes
• . Behavioral outcomes
• . Service outcomes
• .Clinical outcomes
• . Health outcomes
UPDATED CORE COMPONENTS OF CARDIAC
REHABILITATION contd..

1. Continuous quality improvement Programs

2. Continuous Professional Development Programs

Continuous quality improvement Programs
• . Quality can be improved by eliminating defects in the process
and adding features that better meet patient’s needs or
preferences;

• . The patient is to every process and process are improved to meet

the patient’s needs reliably and efficiently

• The main source of quality defects is problems in the process.

Preventing defects in the process saves resources;
Continuous Professional Development Programs

• identify formal and informal continuous learning processes that

update relevant knowledge, skills and attitudes.
• maintain professional continuing education credits obtain ACLS
certification and re-certification
• obtain CPR certification and re-certification
• engage in: employee mentorship of students and other
professionals, journal Club In-services, ACSM/CSEP certification,
annual professional society meetings.
• . Focus on the most important processes to improve- use
statistical thinking and tools to Identify identity desired
performance levels, measure current performance. Interpret it
and take action when necessary

• .involve every worker in quality improvement. Use new

structures such as teams and quality councils to advise and plan
quality improvement strategies.

• . set high standards for performance; go for being the best.

Cardiac rehabilitation Program Models

• Summary

• Regional coordination of CR services facilitates:

▫ Assessment of needs and gaps;
▫ Development of appropriate models with common core components
and evaluative criteria;
▫ Local program human health and equipment resource planning;
▫ Forecasting of appropriate site location and number;
▫ A strong common voice to interface with funding bodies’
▫ Greater success in incremental deployment of CR service.
• CR programs should be patient and outcome focused.