Outpatient/Ambulatory Rehab. Dedicated Trans-disciplinary Team (defined within Annotated References)

CARDIAC The delivery of Cardiac Rehab is unlike most other rehab populations. The vast majority of patients receive their rehab in outpatient or community settings and only a small subset requires an inpatient rehab admission. This framework reflects these differences and is, therefore, unlike the frameworks developed by the GTA Rehab Network for other rehab populations. It should also be noted that leading practices in this area continue to emerge and the components of the framework outlined here are based on current practice at the time of development. Acute Care Integrated Specialized Units * Inpatient Rehab in Acute Care or Rehab Hospitals Outpatient/Ambulatory Rehab Dedicated Trans-disciplinary Team (defined within Annotated References) Home Based Rehab Program * Each Rehab sector is defined by: Services Provided Degree of Specialization Differential Criteria Typical Duration Key Activities / Nature of Services Names Typically Used Frequency of Therapy *All hospitalized patients with a qualifying cardiovascular event should be automatically referred to an early outpatient cardiac rehab program prior to discharge. Source: Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3 rd Edition) p. 392 Rehab Definitions Conceptual Framework December 2010 Page 1 of 15

OUTPATIENT/AMBULATORY REHAB PROGRAMS Dedicated Trans-disciplinary Rehab Team Names Typically Used Services Provided Specialization vs. Non- Specialization Target population Outpatient Cardiac Rehab Programs Core team includes physician, program manager, registered dietitian, and regulated or allied health professionals with expertise in exercise science. The Case Manager role (exercise therapist, exercise supervisor, cardiac rehab therapist) can be filled by any combination of nurses, physiotherapists, and kinesiologists 1. Requisite certification requirements for staff are obtained through organizations such as the Canadian Society of Exercise Physiology (CSEP) or the American College of Sports Medicine (ACSM) 2. Team members involved in on-site stress testing should include staff members certified through the Ontario Society of Cardiology Technologists or equivalent. Consultation available as required from psychologist, psychiatrist, social worker, occupational therapist, pharmacist as required. Team members have knowledge of the evidence supporting cardiac rehab including: the current Canadian guidelines and recommendations regarding prevention, treatment and general risk factor management basic principles of heart healthy behaviour the importance of education in promoting cardiovascular disease risk reduction. basic cardiovascular symptomatology exercise physiology applied to chronic disease population actions and most frequent side effectives of common cardiac medications ECG Interpretation Principles of behaviour modification Transdisciplinary teams work together to share knowledge, skills, and patient care responsibilities. 3 Staff have current cardio-pulmonary resuscitation (CPR) with Automated External Defibrillators (AED) certification. May include a mix of on-site and home based services as required. Development of self-management techniques based around individualized assessment, problem-solving, goal setting. Cardiac rehabilitation programs must meet the requirements expressed in the Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (CGCRCDP) and the American Association of Cardiovascular and Pulmonary Rehabilitation Team members should be certified as cardiac rehab professionals 4. All hospitalized patients with a qualifying cardiovascular event should be referred to an outpatient cardiac rehab program 5 All outpatients with an appropriate cardiovascular diagnosis within the past year who have not participated in cardiac rehab should be referred for cardiac rehabilitation 6. Patients are medically stable and cleared for exercise There is emerging evidence that the cardiac rehabilitation model may prove to be effective for patients with diabetes or stroke and as such, specialized cardiac rehab programs may include individuals with chronic disease such as diabetes, renal disease, TIA and stroke, vascular disease7. Rehab Definitions Conceptual Framework December 2010 Page 2 of 15

OUTPATIENT/AMBULATORY REHAB PROGRAMS Cardiac Rehab Definition Framework Typical Duration Dedicated Trans-disciplinary Rehab Team Program length is based on patient need. The published literature supports program durations from as short as 12 weeks to 12 months 8 The frequency of on-site programming ranges from 1-3 times a week based on patient need and program design. Key Activities/ Nature of Service Cardiac Rehab programs address all aspects of CVD and include 9 : Patient Assessments include: History and physical examination Risk stratification Exercise testing for functional capacity Risk factor assessment Nutritional assessment Psychosocial Assessment Health Behaviour Interventions and risk factor modification: Nutritional counselling Lipid management Hypertension management Smoking cessation Weight management Diabetes management Optimization of pharmacology Psychosocial management Physical activity counselling Exercise training Family/significant others are recognized as key to enabling client function and attainment of rehab goals and are involved throughout the rehab process: Families/caregivers, with patient consent, are included in discussions around key treatment decisions and discharge planning Mechanisms for communication of goals and plans to patients and families/caregivers are established. Emergency plan must be in place with appropriate equipment and staff available during patient care hours 10 Classes are available in the morning/afternoon, evening and are not necessarily held in hospital. Program should strive to meet the needs of a culturally diverse population Rehab Definitions Conceptual Framework December 2010 Page 3 of 15

INPATIENT REHAB FOR A SMALL SUBSET OF PATIENTS A CARDIAC INPATIENT REHAB PROGRAM IS WARRANTED. THESE PATIENTS HAVE MORE CO-MORBIDITIES AND USUALLY MORE COMPLICATED COURSE IN ACUTE CARE THAN THOSE TYPICALLY REFERRED DIRECTLY TO OUTPATIENT CARDIAC REHAB.. THEY MAY ALSO HAVE SOCIAL, MEDICAL, OR OTHER CIRCUMSTANCES THAT PRECLUDE THE PATIENT FROM GOING DIRECTLY HOME FROM ACUTE CARE. INPATIENT REHABILITATION CAN BE AN INTEGRAL PART OF THE CONTINUUM OF CARE FOR A SUBSET OF CARDIAC PATIENTS THAT TYPICALLY CONTINUE IN OUTPATIENT OR COMMUNITY REHAB FOLLOWING DISCHARGE. Names Typically Used Dedicated Rehab Units in Acute Care and Rehab Hospitals Inpatient Rehab: Suitable for individuals in need of an transdisciplinary rehab program and who also require 24-hour hospital care. Inpatient cardiovascular rehabilitation program. Services Provided (types of professionals involved) Intensive Rehab Program of a minimum of 60 minutes of formal therapy per day is available to the patient 5-7 days per week under the direction of a rehab professional. Staffing ratios support, at minimum, the amount of therapy required Rehab program is individualized according to patient need (not necessarily 1:1) Trans-disciplinary team providing rehab has knowledge of the evidence supporting cardiac rehab, basic cardiovascular symptomatology, exercise physiology, and the importance of risk factors in CVD. Core team includes Physician, Nursing, Physiotherapist, Pharmacist, Registered Dietitian, and Social Work, Occupational Therapist, consultation with SLP, Physiatrist, Psychology as required. Team must have knowledge of the current Canadian guidelines and recommendations regarding prevention, treatment and general risk factor management, basic principles of heart healthy behaviours and the importance of education in promoting cardiovascular disease risk reduction 11 ) Access to a regulated or allied health professionals with expertise in exercise science is required. Family/significant others are recognized as key to enabling client function and attainment of rehab goals and are involved throughout the rehab process: Families/caregivers, with patient consent, are included in discussions around key treatment decisions and discharge planning Families (and patients) are encouraged to participate in team meetings(as required) Mechanisms for communication of goals and plans to patients and families/caregivers are established. Comprehensive discharge planning with access and referrals to specialized services and community support programs is provided (i.e., outpatient /ambulatory rehab, specialist followup and/or CCAC) Discharge planning activities are initiated and include, but are not limited to, the following as a modified version of the GTA Rehab Network s Discharge Planning Guidelines for Inpatient Rehabilitation*: 12 Within 24-72 hours of admission, an estimated date of discharge and provisional destination is determined Within 7 days of admission, screening for factors that may delay discharge is conducted and a plan of care for addressing the identified barriers to discharge is developed. Patient/family team meeting for patients at risk for a delayed discharge are held as issues are identified. Weekly team meetings are conducted to promote consistency in the treatment approach by identifying and reviewing the patient s care plan, treatment goals, Rehab Definitions Conceptual Framework December 2010 Page 4 of 15

INPATIENT REHAB Cardiac Rehab Definition Framework FOR A SMALL SUBSET OF PATIENTS A CARDIAC INPATIENT REHAB PROGRAM IS WARRANTED. THESE PATIENTS HAVE MORE CO-MORBIDITIES AND USUALLY MORE COMPLICATED COURSE IN ACUTE CARE THAN THOSE TYPICALLY REFERRED DIRECTLY TO OUTPATIENT CARDIAC REHAB.. THEY MAY ALSO HAVE SOCIAL, MEDICAL, OR OTHER CIRCUMSTANCES THAT PRECLUDE THE PATIENT FROM GOING DIRECTLY HOME FROM ACUTE CARE. INPATIENT REHABILITATION CAN BE AN INTEGRAL PART OF THE CONTINUUM OF CARE FOR A SUBSET OF CARDIAC PATIENTS THAT TYPICALLY CONTINUE IN OUTPATIENT OR COMMUNITY REHAB FOLLOWING DISCHARGE. Dedicated Rehab Units in Acute Care and Rehab Hospitals Inpatient Rehab: Suitable for individuals in need of an transdisciplinary rehab program and who also require 24-hour hospital care. progress and discharge plans. Discharge readiness indicators are considered throughout the admission to determine the appropriate timing for ALC designation. Specialization vs. Non-Specialization Cardiac rehabilitation programs must meet the requirements expressed in the Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention and the American Heart Association/ American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Differential Criteria Typical Duration Key Activities / Nature of Service Designated team with knowledge of the evidence supporting cardiac rehabilitation including: the current Canadian guidelines and recommendations regarding prevention, treatment and general risk factor management basic principles of heart healthy behaviour the importance of education in promoting cardiovascular disease risk reduction. basic cardiovascular symptomatology exercise physiology applied to chronic disease population actions and most frequent side effectives of common cardiac medications ECG Interpretation Principles of behaviour modification 13 Individuals requiring inpatient rehab often have more co-morbidities and usually more complicated course in acute care than those typically referred directly to outpatient cardiac rehab. Patient may also have social, medical, or other circumstances that preclude the patient from going directly home from acute care. Inpatient rehabilitation can be an integral part of the continuum of care for a subset of cardiac patients that typically continue in outpatient or community rehab following discharge. Transfer to inpatient cardiac rehabilitation may occur 5-10 days after cardiac surgery or acute coronary syndrome; usually this is dependent on completion of diagnostic and therapeutic procedures and on medical stability. Length of Stay is typically 10-14 days in inpatient rehab 14,15. The patient typically remains in inpatient cardiac rehab until the patient can be safely discharged and their needs can be effectively managed in an outpatient/community setting. Focus is on patient education, health behaviour intervention and risk management (energy conservation, symptom management, and mobilization prior to hospital discharge) 16 Rehab Definitions Conceptual Framework December 2010 Page 5 of 15

INPATIENT REHAB Cardiac Rehab Definition Framework FOR A SMALL SUBSET OF PATIENTS A CARDIAC INPATIENT REHAB PROGRAM IS WARRANTED. THESE PATIENTS HAVE MORE CO-MORBIDITIES AND USUALLY MORE COMPLICATED COURSE IN ACUTE CARE THAN THOSE TYPICALLY REFERRED DIRECTLY TO OUTPATIENT CARDIAC REHAB.. THEY MAY ALSO HAVE SOCIAL, MEDICAL, OR OTHER CIRCUMSTANCES THAT PRECLUDE THE PATIENT FROM GOING DIRECTLY HOME FROM ACUTE CARE. INPATIENT REHABILITATION CAN BE AN INTEGRAL PART OF THE CONTINUUM OF CARE FOR A SUBSET OF CARDIAC PATIENTS THAT TYPICALLY CONTINUE IN OUTPATIENT OR COMMUNITY REHAB FOLLOWING DISCHARGE. Dedicated Rehab Units in Acute Care and Rehab Hospitals Inpatient Rehab: Suitable for individuals in need of an transdisciplinary rehab program and who also require 24-hour hospital care. Medical management is provided (e.g., assessment and treatment of cardiac and related medical conditions, fluid, arrhythmia, and wound care management) Physical therapy, mobilization and progressive exercise programs (e.g., may start with bed to chair to ambulatory exercises) Nutritional counselling and psychosocial services are provided as needed. Appropriate referral to outpatient cardiac rehab is facilitated on discharge Rehab Definitions Conceptual Framework December 2010 Page 6 of 15

HOME BASED REHAB (associated with Outpatient Cardiac Rehabilitation) Home based programs refer to those programs in which the majority of exercise training is performed in the community without direct hands-on, line of sight supervision by cardiac rehab staff. However, they should not be considered unsupervised programs. The exercise and rehab programs of the patient are developed and monitored by a rehab team at an outpatient cardiac rehab program. Most programs continue to see the patients throughout their rehab for education and individual counselling. Home based programs require careful and systematic risk stratification to ensure the right people are enrolled 17. Names Typically Used Home based Cardiac Rehab 18 Services Provided The majority of exercise training is performed without direct, hands-on supervision by rehab staff. Intent is to provide same services as outpatient program but delivered at a distance. Most CR program will still contact patients 1-2 times per week (more frequently in the early phase of the program) for 19,20 : Education classes Individual counselling sessions Review and Progression of Exercise Specialization vs. Non- Specialization Target Population Typical Duration Key Activities/ Nature of Service Cardiac rehabilitation programs must meet the requirements expressed in the Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (CGCRCDP) and the American Association of Cardiovascular and Pulmonary Rehabilitation Team members should be certified as cardiac rehab professionals 21. There are two types of patients that access home based cardiac rehabilitation: those who are home-bound and can not make it to a hospital because of their medical or social conditions those on the road to recovery and require monitoring, but faces challenges with accessing on-site programs. Home based exercise training programs require careful training and systematic risk stratification to ensure that inappropriate high risk individuals are not prescribed unsupervised exercise training 22, 22. Varies depending on program. Typically 1 visit per week in early phases of program but tapered according to patient need over 3-6 months. Rehab providers typically work as individual providers; however, communication with other health providers occurs on an as-needed basis Case management and chronic disease management models are required to support the delivery of home exercise 23 Referral to disease or population-specific wellness programs that provide health education, goal setting, behaviour change principles and practices to promote health and wellbeing of the individual and secondary prevention is recommended. Rehab Definitions Conceptual Framework January 2009 Page 7 of 15

HOME BASED REHAB (associated with Outpatient Cardiac Rehabilitation) Home based programs refer to those programs in which the majority of exercise training is performed in the community without direct hands-on, line of sight supervision by cardiac rehab staff. However, they should not be considered unsupervised programs. The exercise and rehab programs of the patient are developed and monitored by a rehab team at an outpatient cardiac rehab program. Most programs continue to see the patients throughout their rehab for education and individual counselling. Home based programs require careful and systematic risk stratification to ensure the right people are enrolled 17. Key Activities/ Nature of Service Cardiac Rehab programs address all aspects of CVD and include: Patient Assessments include (assessments and exercise testing can occur on site prior to establishment on home based program): History and physical examination Risk stratification Exercise testing for functional capacity Risk factor assessment Nutritional assessment Psychosocial Assessment Health Behaviour Interventions and risk factor modification: Nutritional counselling Lipid management Hypertension management Smoking cessation Weight management Diabetes management Optimization of pharmacology Psychosocial management Physical activity counselling Exercise training 24 Family/significant others are recognized as key to enabling client function and attainment of rehab goals and are involved throughout the rehab process: Families/caregivers, with patient consent, are included in discussions around key treatment decisions and discharge planning Mechanisms for communication of goals and plans to patients and families/caregivers are established. Rehab Definitions Conceptual Framework January 2009 Page 8 of 15

APPENDIX A: Cardiac Rehab Definition Framework The Cardiac Rehab Definitions Framework is part of a larger initiative to define the components of rehabilitation across all rehab populations. The following guiding principles and definitions were developed to support the overall initiative and are not specific to Cardiac Rehab. Objectives: GUIDING PRINCIPLES I. Increase clarity and consistency in the forms of cognitive and physical rehab across the continuum by: 1. Clarifying the distinctions between and across institutional and community-based rehab programs. 2. Classifying programs with consistent terminology. 3. Describing the key features of institutional and community-based rehabilitation programs based on the services provided, the degree of specialization, differential/critical criteria, duration, and the primary focus of the rehab program/service. II. Inform planning and performance measurement through the development of standards for rehab program components against which rehab programs can be benchmarked. Guiding Principles: 1. The Rehab Definitions Conceptual Framework presupposes the World Health Organization s definition of rehabilitation as a progressive, dynamic, goal-oriented and often time-limited process, which enables an individual with an impairment to identify and reach his/her optimal mental, physical, cognitive and/or social functional level. Rehabilitation provides opportunities for the individual, the family and the community to accommodate a limitation or loss of function and aims to facilitate social integration and independence." 2. The Rehab Definitions Conceptual Framework refers to rehabilitation across the continuum of care (including Cardiac Rehabilitation). The rehab conceptual diagram refers to acute care, inpatient rehab programs within institutional settings and outpatient and community-based rehab for clients residing at home or in a residential setting. The use of bi-directional arrows in the schematic reflects the flow of patients and continuity of care across these settings. Rehab Definitions Conceptual Framework January 2009 Page 9 of 15

3. The framework identifies key features of rehab programs based on evidence-based practices where available to define the gold standard of rehab care. In most instances these key features reflect current practices; however, some organizations may be required to implement changes within their organizations to achieve consistency with the criteria set out in the framework. 4. The term patient is used for individuals receiving rehabilitation in a hospital setting. The term client is used to refer to individuals receiving community rehab services. 5. The Rehab Definitions Conceptual Framework uses categories that have been defined based on the rehab needs of the patient and the typical services provided. Length of stay or the type of facility in which the rehab is provided is not considered essential to defining rehab sectors. 6. The Rehab Definitions Conceptual Framework is based on the assumption that clients participating in the programs described have rehab potential and rehab goals. For criteria regarding rehab potential, medical stability and rehab readiness for inpatient rehab, refer to the GTA Rehab Network s Inpatient Rehab Referral Guidelines (www.gtarehabnetwork.ca). 7. The framework uses terminology that is consistent with the MOHTLC guidelines for inpatient rehabilitation beds and can be applied to community and ambulatory service delivery. 8. While it is appreciated that much of rehabilitation occurs in third-party payer assessment centres or private clinics, the framework refers to publicly-funded rehabilitation. However, it is hoped that the framework will promote consistency in standards of care and equitable access across all rehab programs. 9. Input from healthcare providers representing acute care, regional rehab centres and community-based organizations that provide adult (including geriatric) and paediatric rehab has been obtained to validate the Rehab Definitions Conceptual Framework. Rehab Definitions Conceptual Framework January 2009 Page 10 of 15

GLOSSARY OF REHAB COMPONENT TERMS Cardiac Rehab Definition Framework For Cardiac Rehab, the term Transdisciplinary is used instead of interprofessional. Members of transdisciplinary teams share knowledge, skills and patient care responsibilities across traditional professional boundaries and engage in cross training with respect to patient care skill sets and flexibility in defining specific patient care roles 1. Dedicated Interprofessional Team (Community): Rehab provided in the home, school or work environment by an interprofessional team using a coordinated, integrated approach for specific rehab populations or to reduce the impact of a particular disability. Dedicated Interprofessional Team (Outpatient/Ambulatory Rehab): Outpatient rehab provided by an interprofessional team with expertise in the treatment and assessment of a particular patient population. Outpatient/Ambulatory dedicated interprofessional teams are located in acute care hospitals, rehab hospitals and community health centres/clinics. They provide rehab to patients who require more than one rehab service and a coordinated rehab approach. Dedicated Rehab Unit: An inpatient rehab unit located in acute care and rehab hospitals that serves a single patient population group and provides intensive rehabilitation. Some units may specialize in more than one diagnosis in related populations (e.g. Cardio/Respiratory, Orthopaedic/Amputation, etc.). A dedicated rehab unit is suitable for individuals who require 24-hour hospital care and who are in need of an interprofessional rehab program using a coordinated rehab approach. Low Tolerance Long Duration (LTLD/slowstream) Rehab Program: Suitable for individuals in need of an interprofessional rehab approach to address specific rehab goals who also have chronic/complex conditions requiring 24-hour hospital care and who are expected to benefit from a slower-paced rehab program for a longer duration than is offered in dedicated or mixed rehab programs. LTLD rehab is most commonly delivered in a complex continuing care bed but may also be provided in a designated rehab bed. LTLD rehab programs may be located in acute care, rehab or complex continuing care hospitals. Mixed Population Interprofessional Team (Outpatient/Ambulatory Rehab): Outpatient rehab provided by an interprofessional team, which typically assesses and treats patients from a variety of patient population groups. Outpatient/Ambulatory mixed population interprofessional 1 Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 391 Rehab Definitions Conceptual Framework January 2009 Page 11 of 15

teams are located in acute care hospitals, rehab hospitals and community health centres/clinics. They provide rehab to patients who require more than one rehab service and a coordinated rehab approach. Mixed Rehab Unit: Formerly referred to as a General inpatient rehab unit, this type of unit is located in acute care and rehab hospitals, provides intensive rehabilitation and serves a variety of patient population groups. The mixed rehab unit is suitable for individuals who require 24-hour hospital care and are in need of an interprofessional rehab program using a coordinated approach. Single Service (Community): Individual rehab services that are usually provided through Community Care Access Centres. Single rehab services are suitable for individuals who are in need of one or more rehabilitation services in single specialty area(s)/profession(s) provided in the home, school or work environment. Although clients may receive more than one service, a coordinated approach is not used as rehab providers typically work as individual providers. However, some communication with other health providers may occur on an as-needed basis. Single Service (Outpatient/Ambulatory Rehab): An outpatient rehab service located in acute care hospitals, rehab hospitals and community health centres/clinics that is suitable for individuals who are in need of an outpatient rehabilitation service in a single specialty area/profession. Clients may receive more than one rehab service; however, the services are not provided by way of a coordinated rehab approach. Services may include assessment only or assessment and treatment. Services may be provided during a one-time visit or multiple visits. Wellness Focused Rehab Groups: These groups are provided in an outpatient/ambulatory setting and led by an individual rehab provider or team or rehab specialists to enhance an individual s ability to cope with a particular disability or impairment. These time-limited groups are publicly-funded although a small fee may be charged for materials. Rehab Definitions Conceptual Framework January 2009 Page 12 of 15

ANNOTATED REFERENCES 1 Professional role requirements in CR are necessarily general, broad-based and discretionary. These guidelines outline the recommended professional roles needed for CR programs. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 408 2 The majority of recommendations concerning CR personnel requirements and professional qualifications are derived from discretionary evidence as there is a virtual absence of reliable, scientifically validated information concerning the specific qualifications and expertise of individuals. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 409 3 Members of transdisciplinary teams share knowledge, skills and patient care responsibilities across traditional professional boundaries and engage in cross training with respect to patient care skill sets and flexibility in defining specific patient care roles Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 391. 4 Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 409 5 Comprehensive and exercise based programs of CR have been found to significantly reduce cardiac mortality after acute cardiac events. A recent metaanalysis and review of randomized controlled trials demonstrated a 26% relative reduction in cardiac mortality for CR compared to usual care. Cited in Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 2 6 Ibid 7 The aging population, and the recognition that the benefits of exercise therapy extend to other chronic disease populations beyond those with cardiovascular disease, has significantly increased the scope of practice within cardiac rehab programs. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 449. Varying degrees of research and evidence exist regarding the effect of exercise training on the cardiovascular risk factors for different patient population such as stroke, pulmonary disease, diabetes, etc. Available research is document in Chapter 14 of Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 475-493. 8 Participation in a standard 12 week CR program is known to result in positive changes in health-related quality of life, cardiac risk factors, and cardiorespiratory fitness. A randomized trial of 392 subjects at the Ottawa Heart Institute compared standard (33 sessions over 3 months) vs distributed (33 sessions over 12 months) found no significant between group differences for outcomes. Both program delivery options served patients well. The evidence Rehab Definitions Conceptual Framework January 2009 Page 13 of 15

clearly highlights that CR programs have a number of options in designing and implementing delivery models. Cited in Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 396-7 9 Each recommended CR interventions is supported by evidence which is cited in the Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) Chapters 5, 6, 8, 9, and 10. In keeping with this evidence, the second edition of the Canadian Guidelines highlighted eight important domains that should be included as core elements of a complete cardiac rehab program. These recommendations are in keeping with the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Secondary prevention guidelines from the United Kingdom provide additional input regarding the core elements of cardiac rehabilitation. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P. 391-3. 10 The AACVPR, ACC, and AHA identified performance measures for the delivery of CR services addressing both structure base and process based issues. The need for an emergency plan with appropriate equipment and staff relates to the structure of the program to support safety. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P. 392 11 The majority of recommendations concerning CR personnel requirements and professional qualifications are derived from discretionary evidence as there is a virtual absence of reliable, scientifically validated information concerning the specific qualifications and expertise of individuals. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 409 12 Discharge Planning Guiding Principles and Standards in the GTA Rehab Network s Discharge Planning Guidelines for Inpatient Rehabilitation, available from the Network s Tools for Professionals menu at http://www.gtarehabnetwork.ca/home.asp. 13 Each recommended CR interventions is supported by evidence which is cited in the Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) Chapters 5, 6, 8, 9, and 10. In keeping with this evidence, the second edition of the Canadian Guidelines highlighted eight important domains that should be included as core elements of a complete cardiac rehab program. These recommendations are in keeping with the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Secondary prevention guidelines from the United Kingdom provide additional input regarding the core elements of cardiac rehabilitation. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P 391-3. 16 Ibid Rehab Definitions Conceptual Framework January 2009 Page 14 of 15

17 Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P91-92 18 Arthur and colleagues were able to demonstrate in 242 post CABS patients randomized to either direct-to-hospital or direct-to-home based exercise training that similar improvements occurred in functional capacity. Arthur HM, Smith KM, Kodis J et al. A controlled trial of hospital versus home based exercise in cardiac patients. Med Sci Sports Exerc. (2002); 34:1544-1550. Cited in Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P. 92 19 To be effective home based CR requires regular updating by a CR program exercise specialist. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P. 92 Home based programs utilize limited hospital or clinic visits with regular mail or telephone follow-up by a case manager. The case manager provides ongoing communication to facilitate risk factor modification and interfaces directly with primary care physicians, specialists and the team. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P397 20 Home based programs utilize limited hospital or clinic visits with regular mail or telephone follow-up by a case manager. The case manager provides ongoing communication to facilitate risk factor modification and interfaces directly with primary care physicians, specialists and the team. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P397 21 The majority of recommendations concerning CR personnel requirements and professional qualifications are derived from discretionary evidence as there is a virtual absence of reliable, scientifically validated information concerning the specific qualifications and expertise of individuals. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) p. 409 22 While home based programs have been demonstrated to be effective, it is still recognized that home based CR patients require supervision and significant CR staff contact time. For the present, the patient groups for whom home based CR will ultimately be shown to be safe and the most cost effective are yet to be determined. Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P. 92 22 The key to safety in any home based program begins at the entry point. Sufficient information and data is now available to triage patients into risk categories and low risk cardiac patients should be cleared for exercise programs. The key to patient safety is consistent throughout the literature. Haskell WL. (1994). The efficacy and safety of exercise programs in cardiac rehabilitation. Med Sci Sports Exer; 26(7): 815-823. 24 Canadian Association of Cardiac Rehabilitation (2009), Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (3rd Edition) P. 393 Rehab Definitions Conceptual Framework January 2009 Page 15 of 15