Download 23 The Role of the Physician-Medical Director in Cardiac

23
The Role of the Physician-Medical
Director in Cardiac Rehabilitation
Philip A. Ades, MD
CONTENTS
Introduction
Design and Coordinate Policies and Procedures
Design and Perform Intake Evaluation
Monitor Patient Progress and Adjust Treatment
Plan
Coordinate Program Safety Parameters
and Emergency Management
Communication and Interfacing with Referring
Physicians
Coordinate Regulatory and Reimbursement Issues
Summary
The Future
References
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INTRODUCTION
Cardiac rehabilitation (CR) services are physician-directed and implemented by
an interdisciplinary team of healthcare professionals that include nurses, exercise
physiologists, physical therapists, dieticians, and behavioral specialists (1–3) (Fig. 1).
While day-to-day care issues in CR are coordinated by the interdisciplinary team, the
overall plan of care, formal progress assessments, and backup plans for emergency
management and medical management are coordinated by the Medical Director.
The Medical Director should have a strong background and interest in clinical and
preventive cardiology, exercise physiology, human behavior, and psychology and
should be a team leader (4). The roles and duties of the Medical Director are
summarized in Table 1 and discussed below.
From: Contemporary Cardiology: Cardiac Rehabilitation
Edited by: W. E. Kraus and S. J. Keteyian © Humana Press Inc., Totowa, NJ
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P.A. Ades
Inpatient
Outpatient
Coronary
Event
Intake
Evaluation
Exercise
Prescription
1- Identify patient
2- Smoking relapse
prevention
3- Early activity
profile
4- Outpatient
referral
1- Medical history
and physical
2- Risk factors
measurement
3- Exercise stress
test
4- Vocational
counseling
1- Aerobic training
“Caloric”
vs
VO2/fitness
2- Resistance
training
3- Onsite/home
exercise program
Risk Factors
Treatment
1- Education
2- Counseling
3- Exercise
4- Pharmacology
Long Term
Outcomes
1- Physical
2- Vocational
3- Psychological
4- Clinical
Fig. 1. Elements of cardiac rehabilitation [Adapted from reference (3)].
Table 1
Roles of the Medical Director
1.
2.
3.
4.
Design and coordinate policies and procedures
Design and perform intake evaluation
Monitor patient progress and adjust treatment plan
Coordinate program safety parameters and emergency
management
5. Communicate and interface with referring physicians
6. Coordinate regulatory and reimbursement issues
DESIGN AND COORDINATE POLICIES AND PROCEDURES
Every CR program should have a Policies and Procedures Manual that defines the
clinical and therapeutic activities of the CR service. The Medical Director should act
as a team leader to establish and keep current the Policies and Procedures Manual
and should be a primary teacher of medical management issues to the CR staff. The
Medical Director is also the primary person to assure that policies and procedures are
compliant with medico-legal parameters such that CR treatment guidelines are standard
of care for the community in which the program is based. The hospitals’ legal advisor
and Medicare Compliance Officer should review the Policies and Procedures Manual.
The Policies and Procedures Manual should address the following issues:
•
•
•
•
•
•
•
•
Diagnostic eligibility criteria for patient participation.
Identification of systematic processes to facilitate patient referrals.
Components of the intake evaluation.
Description of exercise training modalities and risk factor treatment modules.
Description of patient education and behavioral treatment modules.
Identification of clinical outcome measures.
Processes for emergency management.
Processes for documentation of daily treatment routines, medical management issues
and communication of results and patient progress to referring physicians.
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• Components of the exit evaluation.
• Planning for long-term exercise and lifestyle therapy.
DESIGN AND PERFORM INTAKE EVALUATION
The Medical Director as team leader should design the CR intake evaluation. The
goals of the CR intake evaluation are several. First, and foremost, is the task of
ascertaining that the patient has an appropriate diagnosis for participation in CR and
that exercise training as prescribed by the Medical Director will be safe and effective.
Second, the clinical stability of the patient is assessed, and pharmacologic therapy is
optimized, both to prevent exertional coronary ischemia and to utilize agents that have
been proven to prolong life and/or prevent major cardiac events (5). Third, cardiac
risk factors are measured or extracted from the medical record, including measures of
lipid profiles, serum glucose, blood pressure, body mass index, waist circumference,
and peak aerobic capacity at exercise stress testing. Fourth, appropriate dietary and
pharmacologic therapies are instituted to treat cardiac risk factors to established goals
(5,6). Finally, the Medical Director, with the input of program staff, should design
an exercise training prescription that is oriented toward attaining improved physical
function and risk factor goals for each individual patient (see Chapters 2, 13, 14,
16 and 17). Exercise training protocols will differ greatly by patient characteristics. For
example, an older women struggling with poor physical function and a need to maintain
physical independence in the home setting will often need an exercise program that
focuses on increasing strength and endurance; so, it is often important to include a
component of resistance training (7,8). On the contrary, a younger male with multiple
components of the metabolic syndrome will need an exercise prescription that focuses
on maximization of exercise-related caloric expenditure, using longer bouts of walking
and other aerobic exercises, to maximize weight loss (9).
MONITOR PATIENT PROGRESS AND ADJUST TREATMENT PLAN
The Medical Director should outline the plan by which progress of the individual
patient is monitored and communicated to the primary care physician. Different models
exist for patients enrolled in CR relative to whether it is the referring physician
or the Medical Director of the CR program that is monitoring patient progress and
adjusting the care plan as needed. In the case where the Medical Director is monitoring
patient progress, it is clear that any changes in the treatment plan should be clearly
communicated with the referring physician, and certainly, no changes in pharmacologic
therapy should be made without the input of the referring physician. On the contrary,
in some programs, the Medical Director is only available for medical emergencies,
with the referring physician performing the intake evaluation and monitoring of patient
progress. In this model, closer contact is needed between the referring physician and
program staff.
COORDINATE PROGRAM SAFETY PARAMETERS AND EMERGENCY
MANAGEMENT
The singular most important role of the Medical Director is to design and maintain
a CR program that is medically safe for participants. Safety protocols include guidelines for excluding highest risk patients, provisions for the closer monitoring of
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high-risk patients, and establishing protocols for emergency management for the rare
but predictable emergencies that include sustained arrhythmias, acute coronary events,
and cardiac arrest. Patients with any of the following conditions or measures should
not enter CR before the condition is stabilized, and if they are already participating,
they should be seen by the Medical Director before continuing in the program (10).
These include but are not limited to
•
•
•
•
•
•
•
•
unstable angina.
severe aortic stenosis.
hypertrophic obstructive cardiomyopathy.
class IV heart failure.
resting systolic hypertension ≥ 200 mmHg.
resting diastolic hypertension ≥ 110 mmHg.
uncontrolled ventricular or supraventricular arrhythmias.
random blood glucose < 80 or > 300 mg/dl until corrected.
As determined by the Medical Director, patients with more severe heart disease may
require closer than usual monitoring which may include extended electrocardiographic
monitoring, more individualized staff contact, more frequent than usual checking of
vital signs, and/or a limitation of exercise intensity. Finally, processes need to be
in place for the care of cardiac emergencies such as myocardial infarction, cardiac
arrhythmias with hemodynamic collapse, or cardiac arrest. The Medical Director or a
designated physician needs to be able to respond to these emergencies within seconds,
and appropriate support staff need to be available. Each day that CR is being performed,
there needs to be written evidence of who is designated as the responsible physician
during an emergency. Intermittent “mock” codes should be performed, and all CR staff
need to be certified in basic cardiac life support while advanced cardiac life support
for some staff is preferred.
COMMUNICATION AND INTERFACING WITH REFERRING
PHYSICIANS
The individual patient appropriately looks to his/her primary care physician for
guidance in making health care decisions. From the point of view of the primary care
physician, CR is part of the overall care plan for the patient with heart disease, and it
needs to be coordinated with other aspects of patient care. Without timely, high-quality
written communication from the CR program to the referring physician, the lifestyles
and behaviors learned while in CR will not be supported or perpetuated long-term.
At a minimum, communication between the CR program and the referring physician
should include the following:
• Baseline evaluation and plan of care.
• A progress report half-way through the CR program.
• A final summary of participation with plans for long-term exercise and preventive care.
Supplemental communications may include updates on clinical events requiring
medical intervention such as changes in anti-anginal medications or the need for
intensification of pharmacologic therapy for improved blood pressure or lipid control.
The Medical Director needs to be available to CR staff in an ongoing fashion to
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evaluate patients when needed and to communicate assessments and possible changes
in therapies to the referring physician when appropriate.
COORDINATE REGULATORY AND REIMBURSEMENT ISSUES
Physician involvement is a major component of obtaining reimbursement for Phase
II CR services because these services are provided “incident to” physicians’ services.
The Centers for Medicare and Medicaid Services (CMS) coordinates the care of more
than 50% of CR participants nationwide; thus, their reimbursement guidelines and
policies are closely monitored and are often adapted for CR coverage for private
insurance carriers. Until recently, CMS covered Phase II CR only for services relating
to the following diagnostic categories:
• Acute myocardial infarction.
• Coronary artery bypass surgery.
• Chronic stable angina with a positive exercise electrocardiogram or imaging stress test.
However, in the new CMS coverage policy for coverage of CR of March 2006,
it has been decided that Phase II CR services be expanded to include patients after
a percutaneous coronary intervention such as placement of a coronary stent, in the
absence of an acute myocardial infarction, patients after heart valve replacement, and
patients after cardiac transplantation but not patients with chronic heart failure (11).
It should be noted that many commercial insurance companies already do provide
coverage for these diagnoses, but these need to be verified on a company-by-company
basis. Because CR coverage remains “incident to” physicians’ professional services,
the patient still needs to be referred to CR by their personal physician and their progress
in CR needs to be followed and documented in the CR chart either by the Medical
Director of the CR program or by the primary physician. This progress report needs to
be done at least once during a 3-month CR program and is in addition to the baseline
and summary reports described above. This same physician will make adjustments
to the plan of care as necessary to maintain patient safety and/or to attain patient
outcome goals. A second issue important to CMS and other health insurance companies
is that a physician be designated to be available to manage medical emergencies in
the CR program. This physician can be the Medical Director of the CR program or,
alternatively, can be the hospital emergency “code” team that is specially trained to
deal with such emergencies in a timely fashion. Finally, CMS requires what is called
“direct physician supervision” of the exercise area during Phase II CR. Technically, this
is similar to what is provided for trained Registered Nurses or Exercise Physiologists to
perform diagnostic exercise stress testing. The physician does not have to be physically
present in the room but must be in the area of the exercise program and thus available
for urgent situations. For example, this might include seeing clinic patients in a room
down the hall if it does not preclude a prompt response, but it would not include
performing medical procedures that cannot be interrupted or being in an adjacent
building. Whereas Nurse Practitioners or Physicians Assistants may perform several
of the roles of the Medical Director such as the intake or exit evaluation of the patient,
the physician supervision aspect of CR must be performed by a Medical Doctor. It is
not clear if a Nurse Practitioner can refer a patient to Phase II CR or if this needs to
be done by an MD.
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SUMMARY
Medical directors of CR programs are optimally situated to assure that systematic
application of behavioral lifestyle treatments and pharmacologic therapies are applied
to attain favorable clinical outcomes in patients with coronary heart disease. As
the leader of the CR team, the role of the Medical Director is pivotal to define
program policies, to perform patient assessments, to communicate in an effective
and timely fashion with the referring physician, to assure patient safety, and to
ascertain that the plan of care is effectively attaining favorable patient outcomes for
participants.
THE FUTURE
Currently, many CR programs have a nurse or Exercise Physiologist functioning
effectively as the program director to design policies and procedures. They cover
medical emergencies with a hospital “code” team. If an urgent clinical issue arises for
a given patient, they need to navigate many barriers to interrupt the personal physician
for clinical direction. However, the personal physician is rarely able to physically come
and examine the patient. Furthermore, the personal physician is rarely trained in the
necessary concepts important to function as a CR staff physician, such as knowledge
of exercise physiology, cardiology, or behavioral change techniques. Optimally, both
the American Association of Cardiovascular and Pulmonary Rehabilitation and the
American Heart Association support the concept that the Medical director for each CR
program be the person responsible to assure that systems are in place to attain favorable
clinical outcomes for participating patients (4). A physician-Medical Director is also
well situated to best communicate with referring physicians.
One shortcoming of the current CR model is that patients at high risk for the
development of coronary heart disease must suffer an acute coronary event before
they “qualify” for a preventive program that is covered by their medical insurance.
A challenge to Medical Directors of CR prevention programs is to develop innovative
preventive services that are affordable within the current reimbursement model. Such
a model might include a baseline risk factor analysis and a symptom-limited stress
test for patients deemed at high risk, an evaluation that is covered by most insurers.
Subsequently, patients can participate in health-club-style prevention programs that can
include exercise, behavioral weight-loss programs, diabetic weight-loss and nutrition
programs, or programs for individuals with relatively asymptomatic coronary heart
disease in the absence of a recent coronary event. Follow-up evaluations would measure
the response of cardiovascular risk factors such as hypertension, hyperlipidemia, and
obesity. Such programs can be made available at reasonable costs, often well below the
equivalent cost of a pack of cigarettes per day. Engaging patients at increased risk of
heart disease calls for an expansion of the current model of what is often termed Phase
III CR. In certain settings, this can also be expanded to include other chronic disease
states where exercise is felt to be beneficial such as rheumatoid and osteoarthritis,
chronic pulmonary disease, mental depression, and the dynamic process of healthy
aging where two overriding goals are to maintain independence and prevent physical
disability.
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Publication No.96-0672; 1995.
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Core Component of Cardiac Rehabilitation/Secondary Prevention Programs. Circulation. 2000;102:
1069–1073.
3. Ades PA. Cardiac Rehabilitation and the Secondary Prevention of Coronary Heart Disease. New
Engl J Med. 2001;345:892–902.
4. King ML, Williams MA, Fletcher GF, et al. Medical Director Responsibilities for Outpatient Cardiac
Rehabilitation/Secondary Prevention Programs: A Scientific Statement from the American Heart
Association/American Association for Cardiovascular and Pulmonary Rehabilitation. Circulation.
2005;112:3354–3360.
5. Smith SC Jr, Blair SN, Bonow RO, et al. AHA/ACC Guidelines for Preventing Heart Attack
and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update. A Statement
for Healthcare Professionals from the American Heart Association and the American College of
Cardiology. J Am Coll Cardiol. 2001:38;1581–1583.
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Panel III), JAMA. 2001;285:2486–2497.
7. Brochu M, Savage P, Lee M, Dee J, Cress ME, Poehlman ET, Tischler M, Ades PA. Effects of
Resistance Training on Physical Function in Older Disabled Women with Coronary Heart Disease.
J. Appl. Physiol. 2002;92:672–678.
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Performance of Daily Activities in Disabled Older Women with Coronary Heart Disease. Med Sci
Sports Exerc. 2003;35(8):1265–1270.
9. Savage P, Brochu M, Poehlman E, Ades PA. Reduction in Obesity and Coronary Risk Factors after
High Caloric Exercise Training in Overweight Coronary Patients. Am Heart J. 2003;146:317–323.
10. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac
Rehabilitation and Secondary Prevention Programs, 4th ed. Champaign, IL: Human Kinetics; 2004.
11. CMS. Available at http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=164 and http://
www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=164.