Despite the fact that cardiac rehabilitation leads to better outcomes for heart attack survivors, only one in five patients currently go down that path. Home-based cardiac rehab programs could be the answer to increasing participation — improving survival rates and presenting ample business opportunity for home health care providers at the same time.
That’s according to a scientific statement recently published by the American Heart Association, the American College of Cardiology and the American Association of Cardiovascular and Pulmonary Rehabilitation.
“The consequences of not participating in cardiac rehabilitation are significant,” lead author of the statement Randal Thomas told Home Health Care News. “They include lower quality of life, lower functional status, lower strength and viability measures, higher rates of rehospitalization, recurrent heart attacks and higher death rates.”
Thomas — who is the medical director of the cardiac rehab program at the Mayo Clinic in Rochester, Minnesota — says a number of factors are to blame for lackluster cardiac rehab participation.
For starters, most programs are of the out-patient variety, forcing patients to come to medical centers to receive exercise, nutrition, psychological training and counseling from health care professionals.
Often, patients may not have access to such programs because of cost, transportation or other factors. Additionally, there are far fewer rehab program spots than there are candidates — individuals who are recovering from heart attacks, bypass surgery, angioplasty, heart failure or other cardiac conditions.
Even if all the cardiac rehab programs in U.S. were filled to capacity, only about 40% to 45% of all patients could be served, according to a 2014 study co-authored by Thomas and published in the Journal of Cardiopulmonary Rehabilitation and Prevention.
“We need more programs — which is not going to be too likely — or we need different programs,” Thomas said. “The home-based approach has the advantage of getting around many of those barriers.”
Successful at-home cardiac rehab programs would likely be supervised by clinicians remotely and could include exercise and diet plans, along with regular check ins.
“The data and research are mounting to show that low- to moderate-risk patients — those who are stable, who have had a cardiac event and who cannot come into a center-based program — would be good patients to consider for a home-based approach,” Thomas said.
What success looks like
Though few and far between, at-home cardiac rehab programs have seen success when implemented.
Take the U.S. Department of Veterans Affairs (VA), for example.
“The people who have participated in our program have lower mortality rates than the people who haven’t, so it’s quite dramatic,” Mary Whooley — the director of cardiac rehabilitation at the VA San Francisco Health Care System — told HHCN. “[But] that’s not a randomized trial. That’s just observational. People who join are going to be healthier to begin with than those who don’t, so it’s hard to say if that’s a cause and effect.”
Through the VA, patients with cardiac disease can choose to participate in a 12-week program, which is entirely remote.
It usually kicks off with a one-time visit to the patient while they are in the hospital for a qualifying cardiac event.
From there, the program becomes telephone- or video-based. VA staff remotely and regularly check in with patients, who receive training in topics such medical adherence and stress management. Additionally, patients regularly report their blood pressure, diet and activity.
However, the program is possible because the VA is a single-payer health care system, Whooley said.
“The main roadblock [to at-home cardiac rehab] is the payment structure,” she said. “Right now, Medicare covers cardiac rehab if supervised by a physician in a medical care facility, and that’s just not feasible for most people.”
That idea is backed up by statistics, as national cardiac rehab participation rates hover below 20%, according to the American Heart Association.
“We really need to … figure out a way to bring the therapy to the patient and not just have this old school notion that patients need to come to the doctor,” Whooley said. “Medicare hasn’t adopted reimbursement strategy, so then there is no way for people to deliver it.”
Thomas agrees, noting that in-home cardiac rehab can’t be adopted on a wider scale until that changes.
“We also need to find a way to cover the expense and reimbursement issue,” he said. “Is the patient going to pay out of pocket? Is there health insurance coverage that’s going to be applied? We need to figure out the mechanism for covering the cost of this important service so it can be applied more fully.”
Additionally, further research and standards for such programs still need to be developed, Thomas said.