AACVPR Paving the Way for Home-Based Cardiac Rehabilitation

Here at AACVPR we’ve been studying the concept of innovative delivery models for both cardiac and pulmonary rehabilitation for the past 18 months. The Innovative Delivery Model Collaborative (IDMC) was formed last year to foster open and consistent dialogue between AACVPR leaders, industry partners, and other professional stakeholders about the challenges, opportunities, and approaches to the real world implementation of innovative delivery models. The Collaborative has been and will continue to be critical as AACVPR considers how to operationalize these delivery models. Huge thanks to Dr. Todd Brown for leading this effort and to the IDMC members and industry partners for their participation.

I’ve asked him to pen this important article explaining our long-term position as it relates to innovative delivery. We’ve been focused on our long-term vision, however the current COVID-19 crisis challenges us to think differently. In addition to reading the article below, I encourage you to bookmark and regularly visit the AACVPR COVID-19 Webpage, which includes up-to-date resources for you as you navigate the impact of this global pandemic.

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AACVPR Innovative Delivery Model Collaborative Leads Efforts for Home-Based Care

By Todd Brown, MD, MSPH, FAACVPR

Many of you have been asking about and, in some cases, already implementing home-based cardiac rehabilitation delivery. We know that you are wondering about what AACVPR’s opinion is on the concept of home-based cardiac rehabilitation in general and to what extent we support this type of delivery. I wanted to update you on what AACVPR is doing to support and promote the utilization of home-based cardiac rehabilitation.

First, I think it is important to point out that traditional, center-based cardiac rehabilitation has decades of clinical trial and observational data supporting its efficacy and has received a Class I (highest possible level) recommendation in numerous American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guidelines.^1-7 Additionally, its use is also supported by current clinical performance measures.⁸ Thus, center-based cardiac rehabilitation really is the “tried and true” and preferred method of cardiac rehabilitation delivery and should be offered to everyone who qualifies.  However, we recognize that despite these data, only a minority of eligible patients attend even one session of center-based cardiac rehabilitation, and even fewer complete the total number of prescribed sessions.⁹

Because of this, AACVPR has been diligently working with Million Hearts^® and others as part of the Cardiac Rehabilitation Collaborative to increase the utilization of center-based cardiac rehabilitation.¹⁰  You are familiar with our communications about this as part of our R2R and Value-Based Care initiatives.  We appreciate your hard work to modernize your programs and build efficiencies to increase enrollment and completion rates for patients in your own cardiac rehabilitation programs. However, despite these efforts, we recognize that numerous barriers to participation in center-based cardiac rehabilitation exist, some of which cannot be overcome simply with increased efficiency in the delivery of center-based cardiac rehabilitation.

As you are also likely aware, AACVPR has recently collaborated with our partners at AHA and ACC to publish a scientific statement on home-based cardiac rehabilitation.¹¹  Although there are still many unanswered questions about home-based cardiac rehabilitation, there are enough data to support its use in patients who are at low to moderate risk and are unable to attend traditional, center-based cardiac rehabilitation.

However, the successful implementation of home-based or other innovative cardiac rehabilitation delivery models will depend upon the close collaboration of cardiac rehabilitation professionals and industry partners to ensure that established standards of delivery that are proven to be successful in traditional, center-based delivery are replicated in a home-based or other innovative delivery environment.  As a result, AACVPR has established the Innovative Delivery Model Collaborative (IDMC), a multidisciplinary coalition of AACVPR volunteers and industry partners, to foster this communication and provide a mechanism for this collaboration.  You will be hearing more from the IDMC over the ensuing months, especially as we approach our Annual Meeting in September.

In the interim, I think it is important to keep in mind that home-based and other innovative cardiac rehabilitation delivery models should not necessarily be viewed as separate and distinct entities from center-based cardiac rehabilitation.  Rather, these are complimentary services.  Home-based cardiac rehabilitation can serve as an adjunct to center-based cardiac rehabilitation and can help to enhance the value of center-based cardiac rehabilitation by providing a way to supervise patients between in-center sessions and perhaps a way to extend the benefits of center-based cardiac rehabilitation once the in-center portion of the program concludes.

In addition, regardless of whether programs are exclusively center-based, home-based, or a hybrid of the two, all cardiac rehabilitation programs should have the content and structure of what you know to be cardiac rehabilitation. Thus, programs should consist of a multidisciplinary team of providers who are led by a physician medical director.  Patients should undergo a baseline assessment and receive an individualized treatment plan (ITP). This ITP should include all core components traditionally included in a center-based cardiac rehabilitation ITP (patient assessment, nutrition counseling, weight management, risk factor control, tobacco cessation, psychosocial management, physical activity counseling, and exercise training).¹² At the conclusion of the program, whenever possible, there should be a completion assessment which includes data collection on key outcomes variables (e.g. changes in functional capacity, risk factor control, psychosocial indices, etc.), just as you currently do in your center-based programs.

It is important to recognize that although the mode of delivery is different, cardiac rehabilitation is cardiac rehabilitation, regardless of whether it is delivered in a center or home-based environment. In this way, we can preserve the benefits of cardiac rehabilitation for our patients while expanding delivery through innovative means.

We recognize that reimbursement is a challenge.  AACVPR will continue to work with the IDMC and our partners at Million Hearts^®, AHA, and ACC as we explore ways to increase innovative delivery and eventually expand reimbursement. However, it is important to recognize that in the ever-expanding value-based care environment, there are benefits to this type of innovative delivery, even if there is not direct reimbursement. I encourage you to advocate for this in your own hospital. We have many resources available through our value-based care initiatives to help support you in this advocacy.

AACVPR is hard at work exploring the benefits and tackling the challenges of home-based and other innovative delivery models for cardiac rehabilitation.  Home-based delivery should not be viewed as a replacement for center-based delivery.  Rather, home-based delivery should serve as an adjunct to center-based cardiac rehabilitation and help to enhance the value of center-based cardiac rehabilitation in those at low to moderate risk who are unable to attend or complete all of their prescribed sessions in a traditional, center-based delivery model.  Stay tuned for updates from the IDMC. Visit the value-based care portion of our website to locate resources to support you as you advocate for innovative delivery in your own institutions.  Lastly, and most importantly, continue to advocate for your patients. At the end of the day, it is your hard work and patient advocacy that make the difference in the lives of the patients that we care for.

References

1. Amsterdam EA, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol 2014; 64:e139-e228.
2. Yancy CW, et al. 2013 ACCF/AHA guideline for the management of heart failure. J Am Coll Cardiol 2013;62:e147-e239.
3. O’Gara PT, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2013;61:e78-e140.
4. Fihn SD, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol 2012;60:e44-e164.
5. Hillis LD, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. J Am Coll Cardiol 2011;58:e123-210.
6. Levine GN, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. J Am Coll Cardiol 2011;58:e44-e122.
7. Smith SC, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. J Am Coll Cardiol 2011;58:2432-2446.
8. Thomas RJ, et al. 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. J Am Coll Cardiol 2018;71:1814-1837.
9. Beatty AL, et al. Geographic variation in cardiac rehabilitation participation in Medicare and Veterans Affairs populations. Circulation 2018;137:1899-1908.
10. Ades PA, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc 2017;92:234-242.
11. Thomas RJ, et al. Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J Cardiopulm Rehabil Prev 2019;39:208-225.
12. Balady GJ, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. J Cardiopulm Rehabil Prev 2007;27:121-129.

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