"Traditional Center-based Cardiac Rehab Model" is a phrase familiar to industry insiders. When heard, most envision a hospital-based outpatient program that expects patients to attend an onsite class three times a week for twelve weeks, leading to 36 billable visits (the insurance maximum). It's a program that appreciates the importance of incorporating all of the "Core Components of Cardiac Rehab" into patient care. However, the insurance billing model only allows for the 31-minute supervised exercise sessions to be billed. Consequently, the remaining aspects and documentation are crammed between exercise classes, creating an overwhelming workload for staff.
Does this scenario resonate with your experiences? I believe it likely does.
Now, let's consider the term "Home-based Cardiac Rehab Model". Here, we may not all share the same vision. This disparity makes it challenging to answer the question, "What is the efficacy of home-based cardiac rehab, compared to traditional cardiac rehab?"
As analyzed by Randall Thomas et al. in their 2021 JCRP article examining Async vs Sync Delivery Models, the included 23 Randomized Controlled Trials (RCTs) studying home-based cardiac rehab employed various delivery models. Some used brief weekly coaching calls, while patients exercised independently. Others used mobile or web apps without real-time communication. Several integrated a few in-center supervised exercise sessions, while others offered none. Interestingly, despite the growing interest in reimbursement for supervised exercise sessions via two-way audio-video (what we term "virtual sessions"), none of these studies incorporated any supervised virtual sessions. All exercise sessions were either supervised in-center or unsupervised and remote/async.
One conclusion consistently drawn from these studies is the beneficial and comparable clinical outcomes achieved by all models, measured against traditional center-based rehab. Moreover, they provided significantly improved outcomes when compared to no rehab at all, which is the population we are targeting with all of these alternative models.
From these findings, we believe that despite the variety in home-based delivery models, many can yield similar clinical outcomes as traditional CR. Importantly, they enhance access and reduce barriers to participation, impacting more patients and saving lives.
Below, we have compiled several key publications demonstrating comparable or superior efficacy of home-based CR programs compared to the traditional model. Our focus there rests on those models that do not include any virtual/video sessions. Given the current lack of permanent reimbursement for these sessions, incorporating them presents financial challenges. Nonetheless, these findings inspire hope and prompt a critical question: "How can we incorporate these delivery models into our existing center-based programs without detracting from them?"
Our answer lies in adopting what we call a "Hybrid Program". This is essentially a blend of several delivery models tailored to your specific needs and population. You can offer different "tracks" based on set criteria, allowing patients to switch between them as their circumstances change. The image below outlines three basic Program Tracks as examples.
As you can see, Track 1 is the traditional onsite program where the majority of patients continue to enroll. Track 2, or "Onsite + Remote", introduces flexibility for patients who are unable or unwilling to attend your traditional track. Here, patients attend onsite supervised exercise sessions once a week, or perhaps monthly, with the remainder of their participation being remote and asynchronous. This includes unsupervised home exercise according to your prescription, home education, vitals tracking, and coaching from your team. Note that a patient on this track may only attend 4-12 supervised exercise sessions onsite. However, they are still completing and tracking remote exercise sessions at home, with the goal of reaching at least 36 sessions. They also progress their MET level at a comparable rate to those exclusively exercising onsite. This equivalent MET level progression is crucial, as it contributes to similar clinical outcomes and benefits.
If an alternative hybrid track can increase CR enrollment and yield comparable or even superior patient outcomes to the traditional CR track, the remaining issue becomes financial viability.
This is where the right technology platform and processes make the difference. We have demonstrated that a hybrid model can be as profitable, if not more so, as a traditional program, while simultaneously increasing patient enrollment and enhancing staff productivity. We are eager to explore which hybrid models could enhance your program, and how many more lives could be impacted by doing so. We invite you to contact us for a discussion about your program's needs and potential opportunities.
Publications Supporting Hybrid Delivery Models without Video Sessions
- Analyzed 23 studies that randomized 2,890 patients into traditional vs home-based CR programs. Some studies included weekly phone calls, but none included video/virtual sessions.
- Results were that there is no significant difference in primary clinical outcomes between onsite and the home-based models for up to 12 months of follow up.
- Tracked 2556 patients, half home-based CR and half onsite CR. Home-based program included one phone call each week, for 8 weeks. No video sessions.
- Results showed that patients in the home-based track, when compared to onsite track, had a LOWER hospitalization rate, and equivalent outcomes for blood pressure, cholesterol, and A1C at 12 months.
- Tracked 1,120 veterans. 490 did home-based CR with 9 phone calls (no video sessions), and the rest did no CR at all.
- Results showed that home-based CR participation was associated with 36% lower mortality rate, compared to no CR participation.
- This provides a very thorough outline of home-based and asynchronous care components, as well as a review of many past studies that tracked home-based outcomes. You'll note that this entire review and the studies included do not contain ANY synchronous video sessions, and it all focuses on onsite and async care models.
- Their conclusion is that these models are safe and effective for low-and-moderate risk patients, and a way to increase participation rates. Today, all three of these professional organizations are even stronger advocates of these home-based models.
We also highlight the yet unpublished results of the study run through the Montana Department of Health for CR sites across Montana, which found equivalent or better outcomes between hybrid and traditional onsite CR, using a delivery model where patients attend onsite sessions monthly, but complete the rest of their program asynchronously at home. This video shows a presentation on their model and fantastic results.
