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In response to added burdens on hospitals as the result of COVID-19, the TAKEheart Team is temporarily postponing regularly scheduled activities. Learn more about the alternate ways that TAKEheart is working to support hospitals during this time.

Strategies for Increasing Referral

Automatic referral alone can increase referral of eligible patients from 32% to 70%.

The first step in improving participation in CR is making sure eligible patients are referred. One successful strategy for increasing referrals is the implementation of automatic referral for all qualifying patients. Automatic referral is a default action generated in qualifying patients’ electronic medical records. Providers would have to actively “opt out” to prevent the referral from moving forward. The goal is efficient, systematic referral to outpatient CR during the discharge process for all qualifying patients. Optimally, this is accompanied by meaningful discussions between physicians or care coordinators and patients about the benefits of CR.

How the TAKEheart initiative helps hospitals increase patient participation in CR

TAKEheart is an initiative funded by the Agency for Healthcare Research and Quality (AHRQ) to help hospitals implement evidence-based strategies for increasing patient referrals and enrollment in CR. TAKEheart provides participating hospitals with training, resources and opportunities for peer-to-peer learning about ways to boost patient participation in CR.

Strategies for Improving Enrollment

Not all patients who receive referrals from their doctors for CR enroll in the program. Patients may fail to enroll because they feel overwhelmed, they lack the information they need to enroll, or they don’t understand the health benefits of the intervention. Research shows that use of care coordinators can significantly address these enrollment barriers. Also known as navigators, coaches, or liaisons, care coordinators begin to work with patients during their hospital stays or shortly after discharge. They help educate patients about the benefits of CR and ensure or confirm that patients are able to enroll in a program. They can help to schedule outpatient rehabilitation appointments at a location that is convenient for the patient. The role of care coordinator can be filled by hospital staff or trained volunteers.

The combination of care coordination with automatic referral can boost CR referral to 86%, and enrollment to almost 74%. Other effective strategies hospitals have used to improve enrollment include addressing patient cost barriers via payment plans or other means, developing motivational videos and educational materials to encourage enrollment, and notifying referring physicians when patients fail to enroll.

Strategies for Encouraging Retention

Once patients enter a CR program, it’s important that they complete the recommended full course of 36 one-hour sessions. The more sessions patients attend, the better their health outcomes.

Patients who attend all 36 sessions have a 47% lower risk of death and a 31% lower risk of heart attack, compared with patients who take part in only one session.

Leveraging Opportunities for Improvement

Helpful strategies hospitals have used to promote patient retention include offering flexible program hours, rewarding patients for attendance, developing a home-based CR option, using automatic appointment reminders, connecting patients to program ambassadors or support groups, and providing progress reports to referring physicians, primary care doctors, or specialists as appropriate (e.g. cardiologists).

Evidence-based strategies for increasing referral, improving enrollment, and encouraging retention can help cardiac patients and hospitals get the most out of CR programs. TAKEheart positions participating hospitals for success in implementing these strategies for their patients.

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Internet Citations

Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K, Newlin K, Shepard DS, Thomas RJ. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Rehabilitation Collaborative. Mayo Clinic Proceedings. 2017 Feb;92(2):234. https://www.mayoclinicproceedings.org/article/S0025-6196(16)30648-6/pdf.

Wall HK, Stolp H, Lucido B, Graff K. Cardiac Rehabilitation Change Package: A Million Hearts Action Guide. Atlanta, GA: Centers for Disease Control and Prevention; July 2018. https://millionhearts.hhs.gov/files/Cardiac_Rehab_Change_Pkg.pdf.

Grace SL, Russell KL, Reid RD, Oh P, Anand S, Rush J, Williamson K, Gupta M, Alter DA, Stewart DE. Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study. Arch Intern Med. 2011 Feb 14;171(3):235-41. https://www.ncbi.nlm.nih.gov/pubmed/21325114.

Department of Health and Human Services. Million Hearts: Cardiac Rehabilitation. https://millionhearts.hhs.gov/files/Cardiac_Rehab_Infographic-508.pdf.