1 Integrating Cardiac Rehab into your Medical Fitness Program Bob Brown MPH MBA Manager Heart Wellness Program At Spartanburg Regional Hospital
2 Faculty Disclosure Presenter has listed no financial interest/arrangement that would be considered a conflict of interest.
3 Spartanburg Regional 588 bed Non-profit Hospital Employees Affiliations MD Anderson Cancer Center Virginia College of Osteopathic Medicine Medical University of South Carolina
4 Staff of the Heart Wellness Program Medical Director Dr. Kibler Administrative Assistants Nina Strange Cheri Murdock Registered Dietitian Barb Toothman Kerri Lindberg Respiratory Therapist Jack Robinson Kris Bagwell Exercise Specialist Ryan Skinner Randy Bates Registered Nurses Marcia T. Hood Shae Shuller Melanie Lawrence Shelia Welch Lori Boyd
5 Heart Wellness Program Fiscal year Oct 2012-Oct 2013 Cardiac Rehab Visits 9,333 1,356 inpatient education Pulmonary Rehab Visits 901 Medical Fitness Program 39,217
6 Learning Objectives Building a continuum of care for the patient through inpatient procedure all the way through post rehabilitation. Understand the importance of clinically integrating Cardiac Rehab into your program. How outcomes will help improve your physician referral pattern.
7 Building a continuum of care for the patient through inpatient procedure all the way through post rehabilitation.
8 First Contact Continuum of Care Starts Patient is seen by Physician to schedule procedure Physician Role Patient is admitted to the hospital
9 Inpatient Clinical Integration Nurses Nurse manager rounding Physicians Secretary Heart Wellness Staff Rounding on Floors EMR Integration Reports Readmission Class Done at Heart Wellness
10 Outpatient Clinical Integration starts with Cardiac Rehab Patient Physical Therapy Occupational Therapy Diabetes Education CHF Clinic Vocational Rehab Mental Health (part of bundle code) Physician Both Cardiologist and Primary Care
11 Understand the importance of clinically integrating Cardiac Rehab into your program.
12 July What is Cardiac Rehabilitation? Medically supervised Lifestyle modification Monitored progressive exercise/activity Inpatient-Outpatient-Lifetime Individualized, typically 3x/week, up to 12 weeks Physician Referral Required
13 What Diagnoses are Covered? Medicare Guidelines: Angina Myocardial Infarction Coronary Artery Bypass Graft Heart Transplant Valve Surgery Stent Coronary Artery Disease (CAD) Private insurance coverage may vary and may cover - PAD - CHF - Cardiomyopathy - Valvular disease
14 July Goals of Cardiac Rehab Identify, modify, and manage risk factors to reduce disability/morbidity & mortality Improve functional capacity Alleviate/lessen activity related symptoms Educate patients about the management of heart disease Improve quality of life
15 July Core Program Components Risk factor management Baseline & ongoing patient assessment Exercise/activity training
16 July Disease Management Components Population Identification processes Evidence-based practice guidelines Collaborative practice models Patient self-management education Process and outcomes measurement, evaluation, and management Routine reporting/feedback loop
17 July Utilization Benefits: Reduced risk of fatal MI (<25%). Decreased severity of angina & need for anti-angina meds. Decreased hospitalizations. Decreased cost of physician office visits & hospitalizations (<35%). Fewer ER visits.
18 July Physician Benefits: Partnership in case management provides: Enhanced access to physician services Consistent surveillance for improved clinical outcomes Improved patient satisfaction Patient education for self directed care Feedback on medications, exercise response and other appropriate issues
19 July Patient Benefits: Improved functional capacity Increased knowledge of heart disease Improved adherence to positive lifestyle changes Better compliance with medical regime Increased self-esteem and confidence Reduced subsequent morbidity & mortality r/t CAD
20 FY Financials Related To CR CR & PR Medicare Reimbursement-Hospital Outpatient Programs by Fiscal Year Unadjusted for geographic location-exact amt will vary Co-payment included in allowed $ amount CR (93798/93797) PR (G0424) Resp Care Services (G ) 2009 $ $ $38 $50 $ $69 $64 $ $67 $38 $ $80 $39 $ (proposed) $102 $39 $39
21 Patient Graduates Cardiac Rehab now what? Typically Phase III Phase IV Lose to other Facility Do nothing
22 How does Medical Fitness Integrate with CR?
23 Traditionally Phase III Cardiac Rehab Out of Pocket Class Schedules Monitored Exercise Session Cost $$$ Phase IV Cardiac Rehab See above Considered Maintenance Phase Bottom Line NO INTEGRATION
24 Barriers We have always done it this way Revenue to CR Program Patient Care will suffer Your staff is not trained SILOS Various programs and bosses
25 Break the Barriers Evidence Based Guidelines Continuous Updates Revenue = Bottom Line Patient Care Improves More time for patient to come More Services Integration
26 How we do it. Refer the patient via their Physician to our MF Program Same Equipment Same Staff Take barriers away Offer a free month Already have done an equipment orientation Reassess the clients every 4 months Continual feedback to PCP Assure we are working on modifiable risk factors
27 How outcomes will help improve your physician referral pattern.
28 Why do we care about outcomes so much?
29 99.9% Rule If you were to operate at 99.9% 20,000 incorrect drug prescriptions will be written in the next 12 months. 12 babies will be given to the wrong parents each day. 114,500 mismatched pairs of shoes will be shipped this year.
30 What is a meaningful outcome? Clarify what you are going to assess I.E. Clinical outcome for Depression pre and post Cardiac Rehab Your outcome must be measureable Can you get criterion to measure the outcome? Intended Outcome must measure something useful and meaningful Outcomes that substantiate what you are looking at How will your outcome be measured? Depends on what you are assessing
31 Outcomes Map Define your map for outcomes What are you tracking? Why are you tracking it? What are you going to do with the data? Who are you collecting data for? When are you doing anything with the data? Are you currently collecting data that you do nothing with? Why? Compare apples to apples not oranges
32 Meaningful Outcomes Help Provide Benchmarking See what is working in a program Financial Models Deliver quantitative data Get creative thinking flowing Promotes problem solving
33 Insanity Doing the same thing over and over expecting a different results, Albert Einstein
34 What do you do with your outcomes? Make sure your math is correct Don t want to give out wrong outcomes Communicate your outcomes Tell the people whom need to know Example coming up Celebrate great outcomes with your staff Share them with your patients Survey results, Results of what being a member of your program dose to their health.
35 What is the common goal? The common goal between the physician and you should be lowering modifiable risk factors of the client. Why Both sides need each other for harmony New CMS guidelines of pay for performance, readmission criterion etc.. Medical Fitness Facilities can t write prescriptions and Physicians can t write EXRX. You want to get referrals to your programs What better way than showing the physician your results with patients Don t forget standard of care is Lifestyle Modification
36 What do Physicians want to know? RESULTS Have you lowered risk factors? BP, TC, LBS. Etc Have you improved quality of life? Have you been able to make a lifestyle modification to the client? Engage your Medical Director Medical Board Random Sample
37 Outcomes Behavioral Domain Goal Percent to Goal Physical Activity 150 min a week 93% Tobacco Cessation Abstinence 72% Medication Adherence >80% 100% Clinical Domain Goal Lipid Management LDL<100 82% Hypertension <140 &<90 82% Diabetes Management <7A1C or FBG % Weight Management BMI<25 or 2% weight loss 50% Psychosocial Absence of depression 89% Health Domain Goal Ed Visits 0 94% Hospitalizations 94% Service Domain Goal Managing Health Better now 90% yes 97%
38 What do we need from the physician? Doctors Clearance ACSM guidelines Refer to ACSM Guideline Book Doctors Care Plan Why are they referring them to your facility? Honest Feedback This helps with process improvement
39 Forms Each Facility should have Set Forms Check with medical director to help aid the creation of these. Types of Forms Prescription Pads Faxes Medical Clearances, and Follow Up information Electronic Medical Record Integration
40 Marketing Yourself There is a profound difference between selling and marketing, selling is trying to get people to want what you have. Marketing is trying to have what people want. When you have what people want, it makes selling unnecessary, Terrence Ryan, a leading healthcare marketing consultant (Lee 2004).
41 What do Physicians want? Depends on the individual physician Some may want: Continued exercise program after physical therapy Weight Loss Lipid Lowering Blood Pressure Reduction Physicians may want one of your service lines and not the rest.
42 How do you get physicians to refer to your facility? Having What they want. How do you do this? Meet with them Get feedback from your medical director Talk to the ones whom are already referring to you Through the client Word of Mouth
43 Why do Physicians want to refer people to your facility? Medical Based Fitness Facility Accredited Staff Supervised Program Continuum of Care Feedback
44 Who are physicians referring to your facility? Clients with medical issues Blood Pressure Diabetes Hyperlipidemia Obesity Orthopedic issues Geriatric people
45 Meeting with Physicians Doctors are people Really Busy Be quick concise and to the point How does your facility help their clients What can you give the doctor about your facility? Prescription Pads, literature etc..
46 Building Relationships with Physicians Roadblocks Stepping on Toes Difference in opinion Not wanting to give up the client Answering the roadblocks Educating physicians on what you do at your facility to ensure that your helping the client get results.
47 Keeping the Relationship Establish the relationship What is next? How do you keep the relationship? Can you undo the relationship? Can you strain the relationship? Can you improve the relationship?
49 Questions? Bob Brown MPH, MBA 299 East Pearl Street Spartanburg SC office
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