Partners in Health: Public Health, Cardiac & Stroke Rehabilitation - PowerPoint PPT Presentation


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Partners in Health: Public Health, Cardiac & Stroke Rehabilitation


Partners in Health: Public Health, Cardiac & Stroke Rehabilitation What is Cardiac Rehabilitation? What is Stroke Rehabilitation? Quality improvement through systems ... – PowerPoint PPT presentation

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Title: Partners in Health: Public Health, Cardiac & Stroke Rehabilitation

Partners in Health Public Health, Cardiac
Stroke Rehabilitation
  • What is Cardiac Rehabilitation? What is Stroke
  • Quality improvement through systems change
  • Current projects with PH and CR
  • Enabling conditions for successful partnerships
  • How can PH and CR/SR collaborate to further
    missions of both?

Cardiac Rehabilitation
  • 3 phases
  • Inpatient (1-4 d stays -gt survival training)
  • Outpatient (OCR)
  • Maintenance
  • Medically supervised and incident to physician
  • Multidisciplinary team Medical Director, RNs,
    EPs, PTs, RDs

OCR is
  • comprehensive, long-term program involving
    medical evaluation, prescribed exercise, cardiac
    risk factor modification, education and
    counselingdesigned to limit the physiologic and
    psychological effects of cardiac illness, reduce
    the risk for sudden death or re-infarction,
    control cardiac symptoms, stabilize or reverse
    the atherosclerotic process, and enhance the
    psychosocial and vocational status of selected
  • US Public Health Service

Candidates for OCR
  • Myocardial infarction
  • Coronary artery bypass surgery
  • Coronary angioplasty
  • Stable exertional angina
  • Valve repair/replacement and
  • Heart transplant
  • Other diagnoses may be covered Heart failure,
    peripheral vascular disease, internal
    defibrillators, ventricular assist devices

OCR Referral Sources
  • Inpatient team, cardiologists, CV surgeons,
    primary care provider usual sources
  • Referral to OCR services historically poor
  • Referral rates 20-35
  • Minorities, elderly, women less apt to be
    referred and less likely to enroll

How it works OCR framework
  • Usually located in hospital/outpt clinic setting
  • 3 months (1-6 month range) duration
  • Medically supervised exercise 2-3 days/wk,
    typically group format
  • Sessions consist of monitoring, exercise,
    education, coaching for lifestyle behavior
  • Discharge based on attainment of goals
  • Follow-up after program discharge based on
    program resources and philosophy

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Aspects of OCR Not just exercise
  • Dietary counseling/weight management
  • Psychosocial interventions
  • Stress management, coping skills, behavior skills
    and goal setting
  • Smoking cessation
  • Diabetes management
  • Lipid/Blood pressure management
  • Medication review/monitoring/adherence

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OCR Treatment objectives
  • Outpatient goals
  • Improve functional capacity and lessen effort of
  • Provide medical monitoring during recovery period
  • Promote healthy lifestyle behavior change
  • Support chronic disease self-management
  • Assist health care providers in treating to
    goal using evidence-based guidelines for
    secondary prevention
  • 20-35 reduction in recurrent cardiac events,
    cardiac-related and all-cause mortality
  • Performance measure for quality care of patients
    with CAD

Challenges in CR
  • Outcomes, outcomes, outcomes
  • Creating new services and maintaining viable CR
    programs with diminishing resources
  • Component(s) of CR that have greatest efficacy?
  • Improving enrollment, retention of underserved

Smith, et al. Circulation, 2006
Partnering with Stroke and Cardiac Rehab
Quality Health Care
  • the degree to which health service for
    individuals and populations increases the
    likelihood of desired health outcomes and are
    consistent with current professional knowledge.

Lohr, et al. NEJM, 1990322
Quality Improvement
Adapted from Rumsfeld 2007
Systems Failures
  • Fewer than 50 of patients who are eligible for
    OCR are referred
  • Of those referred, only 20-30 enroll
  • Of those who attend, 25-50 drop out within the
    first 3 months
  • Only 7 of CAD pts complying with 2dry prevention
  • Minorities, women, older adults and employed
    individuals less served
  • Multiple barriers to referral, enrollment and

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Systems change for QI in CAD/CVD care and
Cooperative projects with DPH and OCR
  • Interventions to reduce recurrent
  • Individual or regional QI collaborations between
    DPH and OCR programs to improve outcomes
  • Registries/outcomes databases
  • Montana and Michigan DPH and Montana CR affiliate
  • WI DPH, WISCPHR and Wisconsin Cardiac
    Rehabilitation Outcomes Registry (WiCORE)

CR Outcomes Projects
  • Montana CVH Program providing data support,
    covering licensing fees for assessment tools, and
    QI offerings for MT programs
  • Michigan DPH covering licensing fees for dietary
    assessment tool and providing training for
    participating MI programs
  • Wisconsin HDSP Program provided funding and
    development support for WiCORE OCR registry for

WiCORE A Collaborative Effort
  • Centers for Disease Control
  • Provided 176,000 as part of Optional Funding
    Grant for secondary prevention efforts in WI
  • WI Heart Disease and Stroke Prevention Program
  • Provided grant leadership, project and accounting
    assistance (Fred Petillo, Project Manager
    Catheryn Brue, Program Coordinator)
  • UW-Madison Division of Information Technology
  • Provided programming expertise and web hosting
    (Dave Conner)
  • WISCPHR (Wisconsin Society for Cardiovascular and
    Pulmonary Health Rehabilitation)

Successful Collaboration
  • Collaboration is a mutually beneficial and
    well-defined relationship entered into by two or
    more organizations to achieve common goals. The
    relationship includes a commitment to mutual
    relationships and goals a jointly developed
    structure and shared responsibility mutual
    authority and accountability for success and
    sharing of resources and rewards.
  • Mattessich, Paul. Collaboration What Makes It
    Work. 2nd ed. 2001. Wilder Publishing Center

Enabling conditions forpartnerships with DPH
  • Purpose
  • Concrete, attainable goals and objective
  • Improve patient care in WI OCR by collecting
    data on current care and outcomes
  • Shared vision
  • Prevent recurrent events and readmissions for
    CAD in patients with established CAD
  • Adapted from Mattessich, P. Collaboration What
    Makes It Work.

Enabling conditions
  • Environment and member characteristics
  • Standards, guidelines that serve as benchmarks
    for performance
  • Evidence-based guidelines for secondary risk
  • Performance measures (AHA/ACC) for referral to
    and delivery of OCR
  • Professional standards of care, core components
    and outcomes management in OCR (AHA, AACVPR)
  • Strong networks of supporting players (OCR
    programs) with history of collaboration
  • Professional societies and state affiliate

Enabling Conditions
  • Interested stakeholders with common goals
  • Patients, clinicians, physicians, administrators,
  • Good communication/valuable feedback
  • Open, frequent communication of results
  • Collaboration must provide important clinical
    information to improve processes, systems of care
    and patient outcomes
  • Information is unique and not obtainable from
    other sources

Enabling Conditions
  • Organizational structure/support
  • Adaptability
  • Partner(s) with necessary clinical experience and
  • Partner(s) with organization skills and support
    structures (DPH)
  • Partner(s) to develop information technology
    needs (software, database, tech tools)

Enabling Conditions
  • Champions and leaders
  • The Champion Person(s) who can promote
    scientific and/or clinical value of project to
  • The Boundary Spanner Person(s) who has
    significant ties to others outside of the
    profession/organization who can link
    participating parties
  • How to Spread Good Ideas, 2004

Enabling Conditions
  • Resources
  • Sufficient funds, staff, materials, time
  • Funding
  • Governmental (CDC, DPH, others?)
  • National or state professional societies
  • State/community health education grants
  • Industry (pharma, biomed devices) grants

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Targets ripe for collaboration
  • Assisting OCR/SR QI initiatives for improving
    secondary prevention efforts, reaching
    underserved populations
  • OCR/SR as conduit for PH promotional activities,
    community education for primary prevention
    efforts, self-management education
  • PH as conduit for promoting referrals to OCR/SR
    to communities, physicians
  • OCR/SR programs as field sites for testing PH
    interventions in CAD, CVD prevention