Good morning to all of you here in person and those of you joining us virtually. Excuse my voice. I am recovering from some sinus troubles. Let me know if you have any trouble hearing me. I want to welcome you to the cardiac rehab session, Improving Cardiac Rehab Referrals and Addressing the Costs of Revenue and the Impact. I would like to introduce our two speakers. Joining us first will be Ginger Biesbrock. She's Executive Vice President of Care Transformation from MedAxiom. Ginger has over 25 years' experience in the healthcare industry with a concentration in clinical care operations and program leadership. Ginger's been an APP for over 20 years working in cardiology, urgent care, and internal medicine. She focuses on contemporary cardiovascular workforce development, strategies in cardiovascular service line design and leadership structures, and cardiovascular clinic strategy development as well as care team development and optimization. So I'm going to welcome Ginger to the stage shortly. After Ginger presents, we'll also be joined by Thomas Vidal, who is the Director of Intensive Cardiac Rehab, the Cardiovascular Institute of the South from Lafayette, Louisiana. Thomas has worked in the medical field for the last seven years with specifically focusing on the rehabilitation of chronic disease patients. He's worked as the lead clinical exercise physiologist in the development and implementation of the Intensive Cardiac Rehabilitation Program for the Arkansas Heart Hospital in Little Rock, Arkansas. Please help me join Ginger as she joins the stand. And then I will take your questions after Ginger and Thomas finish. Good morning. Excited for this session. I appreciate the opportunity to kind of share some of the things that I know both Thomas and I are fairly passionate and actually really passionate about. And I'm going to start off with I appreciated the question in our general session this morning related to kind of health care versus well care, and how do we start to get into the business of keeping our patients well versus more of a reactive approach to disease management. And I would suggest cardiac rehab is a way to do that. Now definitely it's a secondary and you're going to see in order to be reimbursed and kind of the indications, our patients end up with an event that initially triggers it. But this is our ability to transition us from being health care providers to well care providers and start to think about our patients more holistically when it comes to their quality of life and their the wellness that they're able to experience. So cardiac rehab, a missed care opportunity. How many of you saw a difference in your cardiac rehab referral rates from pre-COVID to COVID to post-COVID? So that's my first question. Did you see a drop in your rates kind of throughout that transition? And then for those of you that did, how many have you seen it bounce back now that we're, again, I would still say we're sort of in the midst of this COVID, but are you seeing it bounce back or are you still seeing it at a lower level? If I'm seeing some nods, yes, we're seeing it bounce back. So good. And the reality was many of us had to close our programs or become much more creative about how we deliver that care. But I would suggest we saw a lot of impact and disruption to our work and our workflows and our standard work. And although I've seen head nods, so I know several of you have seen your organizations kind of get back to life as normal. I have a feeling, and I know because I've been out and speaking with people, a lot of our organizations, we haven't gotten necessarily back to normal and that disruption, we haven't really recovered. So some of the things I'm going to talk about today almost take us back to the basics. There's nothing rocket science about this as far as how do we get our patients referred and then enrolled and engaged. But I think with all the disruption that we've been living through, a lot of those processes and workflows that we've had in place have basically disintegrated and we're sort of starting over. So there'll be some good reminders here. And then Thomas is going to give us a great example of how a program has done really well around that patient engagement strategy. It's one thing to refer. It's another thing for our patients to show up and then actually complete the program. So he's going to have some great best practices there. So the goals for the first portion of this, I'm going to kind of walk through a reminder of indications. We'll talk about referral management, patient engagement. We'll talk about some barriers to participation and then some strategies for success. So I'm going to give you all a little bit of homework as we kind of work through here for you to take back to your home organization and ask a few questions and kind of see where you're at. A few reminders, just a level load. Cardiac rehabilitation is a class 1A recommendation. We actually don't have that many of those. And so that right there, it's a do no harm sort of recommendation. We can only help patients when we work them through and get them involved in cardiac rehab. Number two, the benefits of cardiac rehab approach or exceed those of many of our standard therapies and pharmacologic interventions. So again, it's one of those do no harm. It only is going to benefit our patients. However, we are not effective at providing this value mold treatment slash intervention. In fact, when you start to get into the data, maybe we're 20% on this one. So there's a lot of opportunity here and a lot of factors that feed into that. If it was a single magic bullet, I think we'd all be much better at it. The reality is it's multifactorial as to why our statistics the way they are. Oh, apparently I'm not in the camera. Is that better? Okay. Sorry about that. All right. So the lights are much brighter right here. I want to start with a couple definitions. There's two types of cardiac rehab. There's kind of the traditional standard, traditional cardiac rehab or CR. And then there's intensive cardiac rehab. And I'll talk about that in just a minute. Just for a quick review, cardiac rehab, there's three phases. So this is just your standard traditional CR. Phase one is really the in-hospital portion where we start to engage our patients in the hospital. And I actually already see a typo on here because insurance, in fact, doesn't actually not cover phase one cardiac rehab. So a lot of us, if I go back to my old program 15 years ago, we offered phase one cardiac rehab. But for funding reasons, we had to pull back on that. So I don't know actually of that many programs that still are able to offer that due to the funding. Phase two is really what most of us think about as cardiac rehab. So that's the outpatient continuation. That's the 36 monitored sessions. That's the sessions that are paid in a fee-for-service environment per session that our patients attend after they've been discharged, kind of three days a week. It involves exercise and some education. And then phase three is more of a maintenance. And this transitions into more of a self-pay sort of environment where the patients typically manage that on their own. A lot of our programs still do this. It doesn't have as much of the monitoring associated with it, but it's a great related to maintenance and just continued wellness strategy. So 36 monitored sessions. Intensive cardiac rehab or ICR. So both of these are reimbursed by Medicare and many commercial insurers, not all of them. And that's one of the challenges. So when we start to think about our 20%, part of that is a funding issue. Not all of our insurers cover. But intensive cardiac rehab is the second type of cardiac rehab that is, again, funded by Medicare. It's a distinct and separate entity. So it's not just about taking your cardiac rehab program and saying, all right, well, instead of 36 sessions, we're going to do 72 sessions. It actually does not work. What it actually is, it has to be performed or carried out. There's two third-party organizations, and Thomas will walk us through that because his program is an intensive cardiac rehab. But it increases patient education. It includes family education. There's cooking classes and demonstrations along with the exercise, and it's a bit more of a holistic approach to cardiac rehabilitation around those therapeutic lifestyles changes. But it's 72 monitored sessions is what is defined or provided in that program. And as I mentioned, there's only two programs that we can engage with around developing that for our local organizations, and that's Pritikin and Ornish. And again, Thomas will walk us through more of those specifics. But I kind of wanted you to get in your mind there's traditional cardiac rehab, there's intensive cardiac rehab. So let's talk about indications. Heart attack in the last 12 months, percutaneous coronary intervention, coronary artery bypass surgery, current stable angina, so the patient's actively having chest pain but it's considered stable, a heart valve repair or replacement, a heart or heart-lung transplant, and then stable chronic heart failure. So when you start to look at that list and we think about the patients that are in our acute care and our procedural areas, I would suggest outside of maybe some arrhythmia management, almost every one of our patients falls into these categories of indication for cardiac rehab. So a significant portion of our patient population. I mentioned earlier we're not very good at this. We have a lot of work happening related to being better. And one of those things is related to, it's called the Million Hearts Program that is sponsored by the CDC and has a lot of involvement multi-societal involvement around putting together plans, roadmaps, toolkits to make us more effective in not only our referral strategy, our patient engagement strategy, and I would even suggest our patient completion rate strategy. And our overall goal of this organization is to get us to 70%. So again, but we're starting at 20%. And I would again suggest I think COVID actually forced many of us to take a step back and so many of us again are not even where we were back in 2019 or early 2020. So one of the things that I want to talk about today or where I'm going to really focus this portion of the talk is related to that referral strategy and I would even say enrollment because it's one thing to check the box around the referral order. It's another thing to actually engage our patients and engage them through the process of actually showing up on the first day for their cardiac rehab journey. So I would suggest that it starts with early initiation. So I'm going to kind of walk you through some best practices and then I'll transfer over to Thomas who will give you some real-life stories and examples of how this works. What I'm showing in front of you, our organization, So Med Axiom, we did a pretty sizable survey last year of cardiac rehab programs from around the country and one of the questions we asked them were what were the top barriers to cardiac rehab participation for their patient populations? And you can see that the number three barrier was physician referrals. So it was our ability to get that order in place to allow us then to look to enroll those patients and get them into the program. In addition, you'll see obviously the funding is a significant problem. That was the number one, the insurance and the co-pays. And there's a lot of advocacy around this. I saw the advertisement for the legislative conference coming up. And if you've never had an opportunity to get involved, that's a great, great experience. But there is a lot of advocacy occurring related to those funding issues. I mentioned the COVID restrictions. So last year we were kind of still in the middle of that. So that was a significant barrier. But number three being physician referrals or getting those orders in so that we can actually implement this for our patients. So let's talk about those referrals and some best practices. As you can see with the study that I quoted on the right, this is not new. So that's from 1992. But this particular multivariate analysis suggested that the strength of the primary physician's recommendation for participation was the most powerful predictor of cardiac rehabilitation entry. So it's not enough just to check the box. It's what we really need is to have the discussion with the patient by the provider team. I'm going to talk a little bit about Navigator and Liaison. But if we're just putting cardiac rehab on the discharge instructions and sending the patient home and expecting them to follow up, chances are they're not going to follow up. So a few things to think about around that referral. When a provider encourages the patient to attend cardiac rehabilitation, the likelihood of enrollment increases significantly. So as you start to think again, this is going to be one of your homework assignments. So number one, go back to your NCDR registry data and look at your rehab referral rate. And then kind of where has it been? I would trend it over the last couple of years. If it's not where you want it to be, and for most of us it's not, I would then go back to your teams and find out who is in the process or who is part of the discharge planning for these patients. One of the things that I have found with especially this sort of intervention is that although when we think about our registry and the data and the owner of that information, oftentimes our minds go to the operator. So the physician that's providing the service or providing the intervention, the procedure, the surgery, as being the owner of all of these processes or all of these metrics. But the reality is this sort of a process metric doesn't happen until we're thinking about discharge planning for our patients. And in most of our organizations, our patients are admitted to the hospitalist team and cardiology is a consultant. And so we have several handoffs that oftentimes occur, and this is where some of our processes can start to fall away. So as you start to think about we need to improve, where do we start to think about where opportunities might be? One of the first places I would urge you to look at is who is managing the discharge planning for that patient? So is it the cardiologist and or the surgeon, so if it's a surgical patient? Do you have fellows in place that might be part of those conversations? Do you have advanced practice providers that help with discharge planning? What about the hospitalists? Are they the ones that are ultimately signing the order for discharge and maybe even putting together the discharge instructions? Do you have nurse navigators in place that would be navigating these patients through their journey? Or is there a discharge nurse? So start to peel away some of those layers to find out who are the key stakeholders that are involved related to the discharge planning in those patient populations. But the reality is what we're looking to achieve is who is having the conversation with the patient? Who is beginning to engage them in what needs to happen after they go home and what to expect and the importance of the cardiac rehab journey and experience. The second best practice has to do with automatic inpatient referrals. So that's the check the box, and we automatically check the box. We make it the default. So this goes back to your order planning committee or whoever is in charge of putting together those clinical orders. Typically that's a physician, provider-led, administrative-supported sort of initiative. And have we made it easy for our care teams to do the right thing? So it's a Class 1A recommendation. Every patient that meets that certain indication deserves the therapy. Have we made it easy? So is the box checked? And probably even more importantly, are our providers using the order sets that we've put into place? So again, as you start to think about it, if you saw a big change from kind of pre-peri-COVID to post-COVID and a drop in your referral rates, go back and find out what's happening related to our order sets, who's discharging our patients, who's working their way through that process, and have we made it easy for them to do the right thing? In addition, measure and provide feedback on that referral adherence. So again, it has to go to the care team that has the influence or the actual direct responsibility for managing the discharge for our patients. And then the final best practice I want to talk about is, and it's well-founded in the literature, but it's this concept of an inpatient liaison who, by definition, is a healthcare provider or peer mentor that speaks to the patient at the bedside about cardiac rehab and facilitates referral while permitting discussion of the nature and merits of such programs and potential barriers to participation. So this is really your cardiac rehab champion. Now, many of you are going to say, because I've been out and about and I know what's happening, we are in the middle of a staffing crisis, so how am I supposed to be able to go back and ask for another FTE to be this liaison to help bridge all of this? And I would actually suggest I go back to this. When we start to think about those that are indulged in the discharge processes, those can be your liaisons. So who is having those conversations? Who's sitting down with that patient, going through their discharge planning, going through the instructions, going through what needs to be expected? Are they having those very specific conversations around cardiac rehab and the benefits and what patients should expect? Have they been informed and do they have the tools and resources they need in order to have that conversation? So again, I think it isn't necessarily a matter if we have to add somebody else to our team, but it is about understanding who is the team that's currently providing that care and do they have what they need to be effective in this particular responsibility. And actually, the statistics on this are pretty good. So remember earlier I said 70% is kind of our national goal of where we want to get to? Well, this particular study, and once again, this is not new work. The date on this is 2011. But back in 2011, what we learned is that following systematic referral, so that's that check in the box, making sure that everybody, that's the default, in combination with the liaison strategy, created the highest level of enrollment rates in this particular study. They kind of compared several different types of support related to cardiac rehab engagement. This had the highest referral rate, so 70%. It resulted in eight times greater cardiac referral when compared to the standard approaches, even after adjusting for hospital site differences. So combination of getting the box checked and verbally having the conversation with the patient and helping to bridge that significantly increased the enrollment. And then the last one has to do with getting that appointment scheduled. I think one of the things, at least in my old programs and in the different ones that I have visited, oftentimes what we say to the patient is someone's gonna call you. So you'll go home, we want you in cardiac rehab, someone will give you a call in the next couple days and we'll get that set up. I don't know if you have mapped out what happens to those patients in the first couple days after they go home, but they get a lot of calls these days. We got people calling them, asking them about how they are doing, that the hospital's calling, sometimes the clinic is calling, we're doing transitional care management and our nurses are calling. Is this just one more call or are they gonna get the call? So the best practice here is actually getting the patient set up for their appointment even before they leave. So they have their appointment, they can plan for their appointment and they're not waiting or anticipating yet one more phone call that they may or may not answer the phone, especially in that first couple of days. So include that cardiac rehab appointment as part of the discharge plan instructions, that CR liaison role is a great role for this and then don't forget the rest of the processes related to prior authorizations, patient education and that kind of thing. And then the last piece I wanna provide before I'll turn it over to Thomas to kind of walk us through again some really great examples and experiences in this space is just a little bit related to the reimbursement. So I think that is probably when I think about what are our biggest barriers, this is not a well-funded resource for us or a well-funded intervention. In fact, in many cases and when we ask our organizations, is this a moneymaker, a money loser or a break even? We either get an I don't know or I think it's probably a money loser. Now I would suggest and it's a little bit outside of the scope of today's talk, but there's a lot of resources out there. If our organizations are set up well and operationally optimized, they're definitely a break even and potentially even a little bit of an economic win. It's never gonna be a profit center. But I wanted to kind of just show you there's a couple different things to think about when it comes to reimbursement. Number one, there's two different potential locations or sites of service that these programs can be provided in. One is a hospital outpatient department. That would be typically the program owned by the hospital and I would suggest most of the programs are kind of fall into that category. And the second one is a physician office-based location where it's really in the clinic. It's not part of a hospital outpatient department and so therefore the funding is quite a bit different. Because of the site of service, they fall under two different payment schedules. They fall under the outpatient prospective payment schedule if you're a hospital outpatient department. And if you look at the HOPD on the left-hand side, I think it's, yes, it's your left-hand side too, you'll see that the payment per session is about $118 in the 2022 reimbursement model. In the physician office, it falls under the physician fee schedule at about $20 to $25 a session. The services we're asking to provide are the exact same services, but it's done at less than 20% of what the reimbursement is in the hospital outpatient department. And then the second piece of this, when we start to think about intensive cardiac rehab, actually, there's not that much of a gap. In fact, I think there's very little gap between the reimbursement at the hospital outpatient department versus in the clinic setting. So there becomes, you know, this again kind of goes back to, if you're struggling with resources within your organization, I would recommend a deep dive into just kind of place of service. Have we optimally operationalized our program in a way that we're run efficiently related to our staffing and our patient throughput? And but I think the key piece of this is just understanding it's a little bit different depending on the site of service. So with that, I'm going to transfer it over to Thomas. I actually think this is great that we can do both live and virtual. I think I hear him talking somewhere. Thomas, it's great to see you. I'm going to transition. I'm going to let you walk through and then I'll come back up for question and answer. Perfect. Sounds good. Thanks for the introduction. That was a great setup for everything we want to talk about today. I'll hit on a lot of the same topics, but also try to share my experience at our site here to hopefully make it more specific to each location. There we go. So just a quick review, like Dindra mentioned, my site is an intensive cardiac rehab and we partner with the Pritikin program to provide that service at our location. We are a physician office location, so we're not located on a hospital campus. So just some context for that. And like she'd already mentioned, overall, cardiac rehab is a class 1A recommendation for patients who have had a heart intervention and is meant to treat the patients after they experience that event to help them recover both physically and mentally post-intervention. Now, this is beneficial to both the patients and their organization, like Dindra already mentioned, by reducing hospital readmissions, improving recovery times, and reducing the likelihood of another heart attack. So that's what we do at Pritikin. Reducing the likelihood of another event. This class 1A recommendation has similar benefits to aspirin and beta bars and statins. And like Dindra mentioned, this is being covered by most insurance providers, including, but not limited to, Medicare and Medicare Advantage pens. Patients participating in cardiac rehab programs see positive health outcomes in everything from their overall weight to their resting blood pressures, their functional capacity, their cholesterol levels, as well as patient improvements in the reported symptoms of depression and quality of life. And so the structure and format of a cardiac rehab program can vary from location to location. Cardiac rehab is a comprehensive overall, regardless of location. And so in our intensive cardiac rehab program, we see patients three days a week at most, and they come for two hours each time. You know, one hour of that time is telemetry monitored exercise. And this exercise can look different depending on what we have going on for that day. But most of the time it's done in groups, as you can see pictured here. For the exercise, we incorporate cardio exercise, which can include high-intensity interval training, as well as strength training and yoga, all done from a chair. This provides a variety of options for our patients to participate in depending on their interest and functional status. Patients also typically do an hour of education, which varies each day, and maybe a live cooking demonstration one day, and then a hands-on workshop focused on nutrition and exercise and medical management, or even stress management with our behavioral team. And this all is included in the intensive cardiac rehab model, where the patients are structured and managed. It is reimbursed under that model to be able to do both these things. The patients can also do more individualized and some one-on-one consultations with our dietician and our behavioral specialist, or even our tobacco cessation team, if that need exists, providing a variety of options for patients and experiences on a daily basis helps to better engage patients in their overall rehab process and improve appointment retention and compliance throughout the program. And like Ginger has already very well explained, historically, cardiac rehab has been an underutilized class 1A recommendation. Throughout the nation, utilization rates being from Medicare have been as low as 28.6 percent, reported as recently as 2017. This presents a massive underutilization compared to other class 1A recommendations, where aspirins and statins are prescribed at rates as high as 90 percent. Not only are the majority of patients not receiving the potential benefits of cardiac rehab, but neither are the organizations that already provide cardiac rehab as a service. Multiple organizations are leaving healthcare savings and potential revenue on the table by underutilizing a service that they already provide. Here at CIS, we've worked diligently to try and determine the best way to utilize our facility and to reach a 40 percent utilization rate after being open only 33 years. And next I'll talk about some of the best practices that we've attempted or tried to help raise this utilization rate in our own organization, in our own location. And so some of the organizational barriers that can be identified pretty early on is just identifying eligible patients for clinic staff. And this can be solved by the rapidly improving technology of most EMR systems. Here at CIS, we've incorporated a patient flagging system, as you can see here on the right, that helps physicians and nurses identify eligible patients on a regular basis. This helps our doctors not have to worry about all the eligible diagnosis, or if a patient has just come out of a procedure or anything, or what was the last thing they had done, or how recent was it. They can see the icons and identify the patient and potentially discuss with the patient their eligibility with cardiac rehab. EMR generally reports also can be utilized to help identify eligible patients and prioritize specific locations for better enrollment. This is especially useful and resourceful for patient liaisons, as Jennifer had already mentioned, so that that liaison can be the most efficient when they need to be. So maybe there are days in the hospital where patients are having more procedures and so it's busier and it's more efficient for that liaison to be at that hospital that day, versus in the community maybe talking to other providers and other cardiologists that can refer patients. And so these reports and these systems built into our EMRs can help with the efficiency and maybe help with the cost benefit when considering hiring a liaison or dedicating staff to another resource or another job responsibility. And as Ginger already mentioned, automatic orders can be utilized in various ways and in different EMRs, but all have the single purpose of reducing the barrier to referral. And so these automatic order sets are very common in EMRs nowadays, but aren't always utilized for cardiac rehab. Multiple studies, as she mentioned, for a million automatic order sets with EMR can reduce work inefficiencies and errors, as well as increase referral rates within the organization. Some of the most successful states in cardiac rehab utilization always have some form of automatic order sets. So as I mentioned before, the average Medicare referral rate to cardiac rehab was 28.6% for the entire nation, but those states who had automatic order sets were almost always above that rate. And this basically, like she mentioned, works in an opt-out fashion so that the orders generated in the EMR, when an eligible diagnosis is selected in the chart, the physician has to manually uncheck or intentionally select to not send that referral. And then that referral activates an alert that's sent on the back end, so no manual process for the physician or the clinic staff. And that referral is then addressed by either the rehab staff or the rehab team, or like Ginger had mentioned, maybe some of the care nurses or care coordinators at that patient's discharge. These are very common in EMRs. If you have Epic or Cerner, it may already be implemented in some capacity. The pros of implementing an automatic order set is that it's very efficient, it's very easy to measure, and it's very scalable in a work in a large organization. Some of the cons are the upfront potential costs of implementation and potential staff resistance to changes we are all very familiar with now. At CIS, we have a different EMR system, so we have been challenged on whether we can implement an automatic order set. We also have a large organization overall, but we are working to implement an automatic order set currently in our own EMR to hopefully improve our utilization rate above 40 percent. And so another one of our best practices, as Ginger has already mentioned, is a physician champion or liaison, or sometimes a titular of both. You know, physicians' overwhelming support can make a big difference, not just in the patient's participation in rehab, but also other physicians within the company. One of the strongest actions linked to patients rolling cardiac rehab was a patient's physician communicating their support and how cardiac rehab would benefit them as a patient. You know, my own medical director at CIS has presented information on the benefits and progress of the cardiac rehab program to the entire company and all its physicians, including the ones he works with on a daily basis. And so he works kind of as a support person within the clinics and his own peers to support the rehab and, of course, answer any questions or at least feel them to be, if he can't address them, the concerns that other physicians may have. You know, having that champion that can speak and support your rehab program can have such a positive impact by diffusing the hesitation or doubts of other physicians, as well as the clinic staff that support them. We have also incorporated physician incentives, so where the physicians can receive an incentive for the number of visits their patients attend in the rehab program and the overall improvement in health outcomes that patient receives from participating in the rehab program. You know, physician championing can be a crucial component to the success of any program. I can't count the number of times patients have come to their first visit in the rehab program just because their physician asked them to. So physicians and doctors are the foundation of any successful practice and cardiac rehab is no exception to that. So many organizations utilize patient liaisons to help educate and recruit eligible patients for various programs, including cardiac rehab. You know, recruitment could include everything from seeing the patient, as Deidre mentioned, in the inpatient facility, if you have a phase one program, to also ensuring eligible patients that are seen in maybe our own physician offices off the hospital campus. So helping those doctors talk to the patients, speak to them about cardiac rehab, we know that all our doctors are pressed on time and whether they have time to speak to this program or that, a liaison can help bridge that gap. So being that resource for the physicians or the clinic staff, so that's one thing they don't have to do. They can trust that the liaison from the cardiac rehab program is able to speak to the patient, enroll them, and answer any questions, concerns that patient may have. And that just lifts the burden off the physician clinic staff and everything they have going on during that day. And so like Deidre mentioned, they can not only enroll a patient and schedule them for their first appointment, but also reinforce the benefits and referral process of cardiac rehab to the physicians and clinic staff in that location, whether it be the inpatient hospital staff, the cath lab, or maybe post-surgery, or even in the discharge planning as the patient's leaving the hospital. And they're also the single point of contact for any questions or concerns leading up to the first appointment. So they can be a direct contact for that patient leading up to their first appointment. They don't have to go through phone trees or struggle to get questions answered about when their appointment was and what it was about. That person, that liaison can help bridge that gap for the patient to hopefully reduce cancellations and increase retention on that first appointment. They could also provide marketing resources to patients and staff to help communicate what rehab is about. By working with our marketing departments to promote the rehab within the community, they can also help drive outside referrals to our rehab facilities from other cardiologists or physicians within our area. And it's worth mentioning too, at CIS before COVID, we did have a liaison, but over the course of this last year, we have been without one. And we've noticed a significant difference, almost as much as 30 to 40 referrals a month, difference between not having a liaison and having one. And so we've been working within our own organization to figure out what we can do to kind of bridge that gap, like Ginger had mentioned, whether it's with our own staff or some combination of a part-time employee around that. And so that's something we're looking to do in the future. And so like Ginger mentioned, getting those orders is great, but the period of time between the patient being seen in the hospital and their first visit is extremely important. Longer wait times following discharge significantly reduce cardiac rehab enrollment. Research has shown that for every day a person waits to start cardiac rehab, that person is 1% less likely to enroll. We see evaluation appointment cancellations skyrocket once we start scheduling more than four weeks after their discharge from the hospital. At our facility, we do everything we can to start patients who have had cardiac stents within a week of discharge and open heart surgery three weeks post-op. We really try to schedule a patient for their first visit within 14 days of receiving a referral, with the exception of open heart patients. When it comes to retaining the patients after the referral, we found that flexibility is really key. With this in mind, we are open five days a week to take in new patients and see current patients. We set specific times for the patients to come for their rehab appointments when they start the program. So this could look like the patient always doing the rehab appointments on Mondays and Wednesdays at 8 a.m., or always coming in at 12 30 on Tuesdays and Thursdays. At first, this may seem very inflexible, but what we found is that patients complete a higher number of visits when they have more structure and routine in coming in when they feel like it. Basically meaning they're more compliant with the rehab visits because they don't have to remember different appointment times or what the availability of the clinic was or anything like that. They just know I always come on Monday and Wednesdays at 8 a.m. So we have also worked to set up a digital text. We've also worked to set up a digital text reminders and phone reminders where we call the patient before the day before and remind them of their appointment, but also review their general medical history. So then that phone call isn't just a reminder to them. It's actually reducing the time they have to spend in the clinic. And a lot of times they appreciate that phone call because we all know patient wait times is a big barrier to not only to cardiac rehab, but to our physician offices altogether. So they're very eager to reduce any wait times that they have potentially in the future. This also helps reduce cancellations so we can talk patients through any questions they have before their first appointment. And I would be remiss to not mention virtual cardiac rehab as an option. You know one of the biggest barriers to patients participating in rehab after we get that referral is travel and transportation. A large portion of our patient population struggles with travel time from a facility or having readily available transportation. We've been utilizing virtual cardiac rehab over the past 18 months and have been able to provide access and rehab services to patients despite these barriers. Having this as an option to offer patients has allowed us to enroll over 85 patients that we wouldn't have reached otherwise. These are patients that would not have participated in rehab you know two years ago because they could not make it due to travel and transportation. And after completing over 800 virtual rehab appointments at our facility, we can confidently say that we have not had any medical issues or concerns from our virtual patients and our virtual patients complete the same number of average visits as our in-person patients. They also see similar improvements to overall health outcomes when compared to patients who come into the facility. Another initiative that we're working on is a rideshare program. This is actually really current with us and wasn't included when I made the slides, but we're working on a rideshare program where we set patients up that have travel and transportation barriers to bring them into that clinic one time so we can set them up with a virtual rehab. And so they get set up all the resources and tools they need to participate in virtual and they can do all that from home and then we can address the transportation with a rideshare program for that one visit. Our hope is that this reduces the barrier to participation for a lot of our patients in rural communities or in low-income families that don't have those resources available. And finally, as Ginger has already touched on, the finances of any department or organization are critically important to its long-term and short-term success. I don't believe that individual finances can be easily compared across organizations due to the drastic differences in such things as staffing, overhead expenses, location, etc. What I would like to point out is that it's been well documented by the Million Hearts Initiative that organizations can save anywhere from $5,000 to $9,000 per patient in cost from a patient participating in cardiac rehab. These savings mostly come from an associated direct and indirect cost of that patient being rehabilitated to a hospital for a complication. And like we have already mentioned, one of their goals is more cardiac rehabilitation and enrollment. And so the potential gross revenue from one patient, if you have a traditional cardiac rehab program, is anywhere from $2,500 to a little over $3,700 per patient. And while the potential revenue, if you have an ICR program or intensive cardiac rehab program, is anywhere from $4,400 to a little over $7,500 per patient, depending on how many visits that patient completes. And this is all based off the most recent hospital fee schedule that's still pending with CMS that they'll approve at the end of the year. And so both Ginger and I would both appreciate any questions you have. Thank you for listening and your attention today. Thank you very much, Thomas. I appreciate your time. A lot of good information there. And I fully expect you to get a lot of contacts related to your virtual program because we had a large number of questions related to home-based cardiac rehab programs. So I'm sure your mailbox will get full. One of the questions, and we are shortly out of time, but one of the questions that seemed to repeat itself a lot was related to are there any programs that either of you are aware for grants or assistance to help patients with the co-payments for cardiac rehab? Because that is one of the factors that prevents patients from going. Thomas, I'm going to let you start. Yeah, so I know there are specific programs that have grants available, whether it's through their foundations in their hospitals or through the state-funded grants. They are rare to find them, but they do exist. I don't know if you could speak to any specific ones that may be good resources for anybody asking. I would agree with that. The challenge is that when you start to talk about, especially Medicare patients, and this is just one of those really unfortunate, almost counterintuitive sort of regulatory compliance rules, but we have to be very careful about waiving co-pays or even providing additional financial support when we deliver or render services. And there's just some pretty strict rules around it. Because what the concept is, they don't want you providing services that would make you more, I mean there's probably multiple reasons for this, but to steer patients is really kind of what they're getting. So I'll give you an example. Again, back in my administrative days, I couldn't even give a patient a gas card if we happened to mess up on their schedule and they showed up on the wrong day because that could have been looked at as we were providing additional benefits that would create patient steerage. So what I would recommend is there are programs and there are ways to do that, but I would work through your foundation if you have one that's accessible to you, as well as your regulatory compliance department as far as what are the rules around those sorts of activities. Thank you very much. Unfortunately, we are out of time, so we're not going to be able to answer any more questions live. Thank you both for presenting and for our attendees, both in person and virtual, please remember to fill out your survey of the session starting on Friday so that you can get your CME credits. Thank you. Thank you. Have a good rest of your day. Thank you.

cardiac rehab referrals

well-care providers

barriers to participation

best practices

virtual cardiac rehab programs

financial aspects

Q&A session

regulatory compliance