cardiovascular rehabilitation and secondary prevention – why is it so important?
TRANSCRIPT
Cardiovascular Rehabilitation and Secondary Prevention –
Why is it so important?
What is Cardiac/Cardiovascular Rehabilitation (CR) and Secondary Prevention (SP)?
“Cardiac Rehabilitation describes all measures used to help
people with heart disease return to an active and satisfying life
and to prevent the recurrence of cardiac events”
“…..it involves medical care, control of biomedical and
behavioural risk factors, psychosocial care, education and
support for self-management”
I’m confused, is it Cardiovascular or Cardiac Rehabilitation or Secondary Prevention?
These are all similar terms which are often interchanged.
Cardiac/Cardiovascular Rehabilitation is often time-limited, a
component of the Secondary Prevention continuum that is lifelong.
Cardiovascular is often used instead of Cardiac as a more
encompassing term for Rehabilitation that is offered to people at
high risk of cardiovascular disease or who have peripheral
vascular disease.
It doesn’t matter so much what you call it
as long as the patient gets referred for it!
Evidence for Cardiac Rehabilitation and Secondary Prevention
Improves survival 1-4
Improves: functional status, cardiovascular risk profile, quality
of life, resulting in fewer psychological disorders and
unplanned hospital readmissions 5-7
and saves money 4,8
People with peripheral arterial disease also benefit9
Important messages
CR and SP is part of usual care
It’s everyone's job to help ensure
that all patients have access to CR
and SP
CR and SP is as important as
medications or surgery
Must be flexible and accessible
What is the problem?
CR programs are effective if people attend…BUT participation rates can be as low as 10 - 30%.
Recent evidence (SNAPSHOT study):27% acute coronary syndrome patients received optimal in-hospital preventive care.
‘Optimal care’ means receiving lifestyle advice, referral to rehabilitation and prescription of secondary prevention drugs.
STEMI, NSTEMI, PCI/CABG during admission or history of hypertension were more likely to receive optimal preventive care.
Older patients (>70yrs) or admitted to private hospital = less likely to receive optimal care.
What policy do we have?
http://www.healthnetworks.health.wa.gov.au/docs/1405_CRSP_Pathway_Principles_WA.pdf
plus Quick Reference Guide and
Consumer information sheet …insert link
CRSP Pathway Principles
Part 1: Pathway overview Part 2: More detail – colours corresponding to part 1
Who is eligible ?As stated in the pathway….
All inclusive
Heart patients and those at risk
Young and old
Not just patients with Acute Coronary Syndrome
For primary care and hospitals
● Needs Assessment, Education and Resources ● Assessment on presentation by Nurse (Ward or Primary Care), Allied Health, Aboriginal Health Professional, GP and/or Medical (team) to determine individual needs, assess self-management capacity and commence education (Detail section 5a: additional
information)
This is where education starts and resources are provided
All health professionals have a role to play here
Reinforcement by many members of health care team is
important
Consider an assessment tool such as CRNAT http://www.heartonline.org.au/SiteCollectionDocuments/Cardiac%20rehab%20needs
%20assessment%20tool.pdf
▲Spectrum of Complexity ▲
HIGHER COMPLEXITY CARDIAC
CONDITION OR NEEDS
LOWER COMPLEXITY CARDIAC CONDITION OR
NEEDS
AT RISK OF CARDIAC CONDITION(MOD TO HIGH ABSOLUTE RISK)
To determine complexity, criteria suggested but not set in stone
Position on spectrum helps determine the level of support needed
Intensity and duration vary depending on:
Needs (physical, medical, functional, cognitive, psychosocial)
Preferences
Available resources
♦ Referral ♦
♦ Referral & Case management ♦ Referral: By Nurse, Allied Health, Aboriginal
Health Professional or Medical team to specialised cardiac rehabilitation service(s) most acceptable to person Case Management: By Cardiac Rehabilitation Coordinator, Heart Failure Nurse, telephone-based service provider or other before discharge or within the week after, to assess and plan early commencement of rehabilitation
Referral: by GP, Primary Care Nurse, Aboriginal Health Professional to secondary prevention
service(s) most acceptable to person
Referral to the most appropriate and accessible service Periodic assessment and/or case management whilst encouraging self
management Variety of ways to receive education/support & encourage behaviour
change Commence CR early.
♥ Secondary Prevention & Ongoing Care ♥
♥ Cardiac Rehabilitation ♥
& Ongoing Care
Education, Self Management & Behaviour Change
Individual Consultation and/or Chronic Disease/ Secondary Prevention / Healthy Lifestyle Program.By GP, Primary Care Nurse, Allied Health and/or
Aboriginal Health Professional
ExerciseCommunity based exercise program and/or
Individual exercise advice
Psychosocial Support+ Peer support group
+ Individual consultation By GP, Primary Care Nurse, Allied Health,
Aboriginal Health Professional and/or Psychologist.
Medical Follow-up Regular GP visits
Specialist if required
Education, Self Management & Behaviour ChangeSpecialised group, individual and/or telephone
education.(Detail section 5a: additional information)
Exercise
Specialised group and/or specialised individual exercise advice
Hospital based if clinically indicated or at patient’s request.
Psychosocial Support
+ Group Education Sessions (and/or peer support) + Individual Consultation (face to face or telephone)By Case Manager, Allied Health and/or Psychologist.
Medical Follow-up
Cardiology follow-up appointment post discharge
©2014 National Heart Foundation of Australia
Registrar assesses patient, determines complex education needs and refers to Heart Failure Nurse
Heart Failure Nurse visits Jack in out-patient clinic. Commences education and arranges to follow-up via telephone
Heart Failure Nurse:1.Provides telephone follow-up2.Supports titration of medications3.Liaises with GP4.Refers to physio for exercise5.Once stable refers to chronic disease self management program
Case study 1: Jack 74 year old from Midland, presents to tertiary hospital cardiology out-patient clinic for cardiology follow-up. Non STEMI 6/12 ago, presents to clinic in Heart Failure.
©2014 National Heart Foundation of Australia
Assessed on ward by nursing staff, education commenced and referred to CR coordinator. Some anxiety and concerns re returning to work. Higher complexity needs detrmined.
CR coordinator phones patient at home 3 days after discharge and assesses progress. Refers patient to DYHS heart health program
Cardiac Rehab coordinator at DYHS contacts patient and enrolls him into the program for education, exercise and support. Cardiology outpatient appointment and GP follow-up, including liaison with DYHS CR Coordinator.
Case Study 2: 48 year old Aboriginal gentleman from Bayswater admitted to Tertiary Hospital following STEMI, underwent PCI
©2014 National Heart Foundation of Australia
GP assesses patient, determines at risk of cardiac condition with education needs and refers to practice nurse for follow-up
Practice Nurse and GP:1.Ongoing support and education and assessment of risk factors2.Referral to dietitian and QUIT program3.Referral to healthy lifestyle program
Case Study 3: Sam 52 year old presents to GP. Is a smoker, overweight, has hypercholesterolemia and high absolute risk.
©2014 National Heart Foundation of Australia
GP assesses patient, determines that he has require some support. Commences mental health care plan, refers to Clinical psychologist and refer to CR program for exercise.
Practice Nurse and GP:1.Ongoing support and education and assessment of risk factors2.Follow-up with clinical psychologist3.Specialised CR exercise program
Case Study 4: Mr X, 65 year old presents to GP. Hx: STEMI 3 months ago, expressing fear of having another heart attack, showing signs of depression and anxiety.
©2014 National Heart Foundation of Australia
GP assesses patient, and explains options for support and lifestyle modification. Patient chooses services most suitable
Case Study 5: Mrs Y, 44 year old presents to GP. Recently discharged from hospital following admission with NSTEMI. Patient refused CR referral, has multiple risk factors and reluctant to take medications.
©2014 National Heart Foundation of Australia
GP assesses patient, determines lower complexity cardiac condition and refers to:Practice NurseCardiac Rehabilitation CoordinatorCardiologist for review
Practice Nurse and GP:1.Ongoing support and education 2.Referral to Community exercise program
Cardiac Rehabilitation coordinator enrolls patient into cardiac rehabilitation education sessions and liaises with practice nurse re progress.
Case Study 6: Simon 67 year old man with history of STEMI (2010) presents to GP for routine check. Has stopped taking meds, over-weight and some recurrent angina. No S/L nitrates or knowledge of angina Mx
What’s the Heart Foundation role in improving Cardiac Rehabilitation in
Australia?
What resources are available?
http://www.heartonline.org.au
http://www.heartfoundation.org.au/information-for-professionals/Clinical-Information/Cardiac-rehabilitation/Pages/default.aspx
Important messagesCR and SP is part of usual care
It’s everyone's job to help
ensure that all patients have
access to CR and SP
CR and SP is as important as
medications or surgery
Must be flexible and accessible
Thankyou
If you have feedback or any concerns, about the content of this presentation or supporting materials please email the Cardiovascular Health Network on [email protected]