Glenn Bean, M.S., FAACVPR

Transcription

1 Glenn Bean, M.S., FAACVPR Tacoma General Hospital/Preventive Cardiology 6/18/2014 1

2 Journey to Date: 2001: AACVPR formal request for coverage of CR for HF patients 2006: CMS- No (Yes for PCI, valve repair/replacement, transplant) 2013: AACVPR/ACC/AHA/HFSA formal request for coverage of CR for HF patients 2014: February CMS announces that HF will be covered as an indication for CR. CMS Eligibility criteria were derived from HF-ACTION Trial for patient eligibility Journey Not Done: Request included HF patients with preserved (normal) EF and those with EF =40%. 6/18/2014 2

3 Patients with stable, chronic heart failure meeting all of the following: 1. Left ventricular ejection fraction 35% 2. NYHA class II-IV symptoms despite being on optimal heart failure therapy for at least 6 weeks. 3. Stable=have not had recent six weeks or planned 6 months major cardiovascular hospitalizations or procedures. Unclear on eligibility criteria? See handout FAQs from AACVPR. Work with Medical Director or referring doc to evaluate medical eligibility. 6/18/2014 3

4 Establish a referral with eligibility criteria documented (ideal). Work with HF Clinic, Medical Director, physicians and allied health staff to support referral, education and coordinate patient care. Private insurance and Medicaid may not be up to speed on CMS guidelines for HF coverage. Don t assume coverage. Flag and track HF CR patients from the beginning to see if there is an impact on readmission rates. (VERY IMPORTANT). Outcomes: 6 minute walk test, Minnesota HF Questionnaire, others? AACVPR CR registry. Same CMS CR guidelines apply (except HF not covered for Intensive Cardiac Rehab programs). 36 visits, 36 weeks etc. 6/18/2014 4

5 Estimate program capacity/patient volume. Integrate patients gradually in the beginning. HF patients may require more individual attention. Inpatient and outpatient strategies. (6 weeks post discharge). Referral generated prior to discharge. Compliance factors: Transportation, Support Systems, State of Readiness, Health Status. 6/18/2014 5

6 Multiple co-morbidities can affect exercise compliance and progression. Large variation in exercise tolerance from severely reduced to moderate reduction progress individually and appropriately Arrhythmias and poor blood pressure response are both common in HF patients. Patient s can be very de-conditioned initially and may be tired later in the day. Progress duration and frequency before intensity Otherwise, test and train using standard practices. 6/18/2014 6

7 Type: Aerobic, dynamic such as walking or cycling. Frequency 3-5 days. Duration: minutes (Progression) Intensity: 55%-80% of heart rate reserve Ratings of perceived exertion (11-14) for patients where heart rate reserve is not adequate. Quantifying Exercise Dose: Volume: MET-hours per week. Hours per week x average exercise intensity during training (METS) 2.0 hr/wk x 2.0 MET activity (eg. 1.4 mph) = 4.0 MET hr/week. 3-7 Met Hours per week goal. 6/18/2014 7

8 Higher repetition, lower resistance muscle specific exercises. Fixed weight machines or hand-held weights. Avoid free-weights. Intensity: 50-70% of 1 repetition maximum for lifts involving the hips and lower body % of 1 repetition maximum for lifts involving the upper body. Frequency 1-2 days per week. 1-2 sets per day reps per set. Total time minutes. Evaluate orthopedic limitations prior to starting. 6/18/2014 8

9 Some research to support benefits of this type of training. However, proceed with caution use in selected patients that first demonstrate tolerance to standard training and progress to moderate intensity interval training (> 3 sessions). Free of: Afib Pacer/ICD Moderate or severe aortic stenosis Complicating musculo-skeletal disorders. Progress from 1 time per week at 2-3 work intervals to 2-3 times per week at 4 work intervals. Vary modality. Review protocols for HIIT and MIIT for HF patients. 6/18/2014 9

10 Increased dyspnea on exertion or at rest. Increased fatigue Productive cough New onset/unexplained resting tachycardia Swelling in ankles, feet, abdomen Weight gain: 3 lbs in 3 days.5 lbs in 1 week. CHANGE in Frequency, Intensity, and Duration of symptoms. Follow-up with health care provider and educate patient on when to notify health care provider. 6/18/

11 Coordinate and support HF education provided by HF Clinic or educators. Be on the same page. Assess factors that can impact self-care abilities: ie. co-morbidities, depression, cognitive impairment, poor functional status, poor health literacy, social isolation, and sleep disturbances. Cardiac rehabilitation staff need to screen, educate, and follow-up on self-care management and maintenance activities. Team approach. Teachable Moments and Motivational Interviewing. 6/18/

12 Signs and Symptoms/When to follow-up with health care provider. Medications Nutrition/Sodium/Salt Fluid Intake Daily Weights Exercise/home Depression Cardiovascular health risk reduction topics. Community Resources 6/18/

13 American Association of Cardiovascular and Pulmonary Rehabilitation: NW Assn of Cardiovascular and Pulmonary Rehabilitation: Heart Failure Society of America: Self-Care Measurements: Self-Care of Heart Failure Index: European Society of Cardiology website for patients: American Association of Heart Failure Nurses: National Salt Reduction Initiative: Ades PA, Keteyian SJ, Balady GJ, et.al Cardiac Rehabilitation Exercise and Self-Care for Chronic Heart Failure, JACC: Heart Failure 2013;Dec;1(6): (Good Article) Highly Recommended! 6/18/

14 Self-Care and Cardiac Rehabilitation is critical for HF patients survival, reduced readmissions, and improvement in quality of life. Cardiac Rehabilitation will now be part of the solution. Our Time Has Come. Questions? Thank You! 6/18/