Cardiac Rehab, the Past, Present and Future - an Interview with Adam De Jong
In this interview, we talk to Adam DeJong, former president of American Association of Cardiovascular and Pulmonary Rehab. Mr. DeJong received his Master of Exercise Physiology from Central Michigan University and has been practicing in the field of cardiology for 21 years, starting as an exercise physiologist. He transitioned to manager of cardiac rehab and then manager of cardiology services at two different hospital systems, Beaumont Hospital in Royal Oak, Michigan for 15-years before moving to his current role as manager of the cardiovascular service line at Genesys Health System, which is part of Ascension Health.
As part of his role within AACVPR, Mr. DeJong is a Fellow of AACVPR and a member for the last 13 years. He has served in multiple committees, both as a member and as a chair. Most recently, he served on the board of directors as treasurer and just completed his tenure as President of AACVPR. As part of this interview, we discuss the idea of open-gyms, home-rehab and how cardiac rehab will evolve in the future world of bundles and value-based care.
MA: You’ve had a pretty star-studded career for the last decade-and-a-half. What kind of practice and policy-based changes have you seen in cardiac rehab from when you started to today?
ADJ: When I first started, cardiac rehab was very structured - very much class time mixed with education that was done as a lecture at specific times throughout the course of the week or the month. People would come in three times a week at their set time, get on equipment and do their standard exercises that were programmed for them. It was very much a robotic-type atmosphere that covered a very small number of diagnoses. Since then, the diagnoses that are covered have expanded greatly to include angioplasties, stents, and now include heart failure.
Most recently, there has been increased utilization of resistance training, more flexibility in how classes are offered. A lot of sites have moved to less class times, more open gym-type concepts, a decrease in the amount of monitoring needed and utilizing risk assessment to determine what patients need throughout the course of their treatment. Higher numbers of patients are entering cardiac rehab as it has increasingly been found to be safe and beneficial to even those who are at a higher-risk for developing issues throughout the course of their treatment.
It’s been a very fast-changing environment and I hope to continue to see these changes throughout.
MA: It sounds like especially in the last three years, there has been a rapid shift in the landscape that is evolving very quickly. One thing in your answer struck me, this idea of an open gym and risk assessment-based rehab. How are you implementing those concepts in your center and how do you see other centers doing the same?
ADJ: I’ve seen a couple of models, and we’re advancing those concepts a little bit in our practice. We still have class times. However, we do have flexibility as to when they can come so they’re not restricted to having to come at a particular time and can reschedule themselves at a different time that they would like. We have certain facilities, one rehab center in Nashville is a prime example, where they have open gym times. Basically, they show up when they want to between certain hours and work with the specified exercise physiologist or nurse, whoever is covering during those hours.
That center has found a lot of flexibility with that model - they’ve been able to increase enrollment and utilization. From my conversations with that clinic, they are now exploring other options to increase adherence because people don’t have the limitations and the difficulty of making a scheduled class time any more.
Also, they complete their education right there on the floor with the patient or the participant. In this way, they’re able to really utilize their time in a very manageable and very effective manner. We’ve taken that concept here at our facility and have done more education and one-on-one conversations, more of a coaching discussion. We utilize things like ‘Question of the Day’ and teaching tools that rotate through a screen so they can give them information and answers just as they are willing to soak it up. It initiates a conversation when you’re sitting there talking to them, you can get multiple topics included versus having to sit there and teach one-on-one to a specific, maybe not beneficial conversation.
MA: That makes sense. It’s interesting because it promotes a flexibility to patient schedules, which is one of the main barriers that prevents patients from participating.
ADJ: It’s one of the biggest barriers, for sure.
MA: Are there other ideas that you’ve seen that have been popular to address the same issue - how else can we address barriers of patient schedules and inconvenience?
ADJ: I think expanding the work day. Even if it’s not every day that you’re open but maybe two or three days a week. Expanding the days into the mornings or into the evenings to better accommodate those who have working schedules. That seems to be a big and popular offering. I know a lot of facilities are open on Saturdays to help bring in additional opportunities for people who may be unable to come during the week due to work schedules. That seems to be popular, as well. Saturday classes are also popular for those individuals who maybe have difficulty with transportation or have family members that may be more available on Saturday to get them here, or in the evening to get them there. That allows for a breakdown of that potential barrier, as well.
MA: What is your view on non-EKG monitored rehab. What are the changes in practices you’re noticing with respect to this form of rehab?
ADJ: I’m noticing that they’re taking a lot more consideration into the individual and looking very closely at their risk of developing any problems throughout the course of their rehab. For those who can progress quickly due to a lower-risk, or have done well initially during the course of their rehab, I see a much greater interest and a better comfort level among the clinicians who work with these patients to transition them to a non-monitored session more quickly when they feel those patients are ready.
The one thing I think the research has shown is that the significance of running into problems relative to them being monitored, is pretty small. Being able to transition someone into a non-monitored session actually helps prepare them a little bit better for life after the rehab center. It gets them more comfortable and more aware of what they should look for, as far as symptoms or problems that could arise. It gives them an idea of how to be more independent while exercising. That then spurs some additional activity outside the center. Maybe they’ll walk more or do some additional exercises when they’re away from the center. That creates a comfort level and ends up benefiting them much more.
MA: It sounds like it’s preparing them for the outside world and getting them to be a bit more self-sufficient, which is the long-term goal of rehab anyway.
MA: Given the new initiatives you spoke about – about tailoring EKG monitoring according to patient progress and needs, does Medicare reimburse EKG monitored rehab differently? Is there a drop in reimbursement or a drop in revenues if one does more non-EKG-monitored sessions? From the point of view of justifying the feasibility of your programs to your management, does it matter?
ADJ: To answer the first part, with Medicare, no. They’re reimbursed at the same level. You end up, not really losing money but you gain a little bit of flexibility and a little bit of an ability to work more with the individuals who are monitored and a little bit at a higher risk. But you are still working, very fully too, with the others during the course of their time in the rehab center. The ability to transition away from the monitor opens up a little bit more flexibility and allows you to really utilize your services more. You’re no longer limited by the number of monitors that you have or by classes at set times, only by how you’re able to work individually with those patients or within a comfort level of the clinicians, creating an environment where safety is still high but the patients are still comfortable and functioning very well.
Most facilities who are still running in what we consider the older processes and are running on a limitation due to monitors, could find themselves increasing enrollment and increasing adherence and utilizing their times that are available to a greater extent, making up maybe for some drop in revenue if there is a drop from certain insurance carriers.
MA: Switching gears a bit, there’s a big elephant in the room in cardiac rehab now, which is the cardiac bundles that are coming in. Could you talk a little bit about how AACVPR and your own hospital are preparing for these bundles that are coming? What are your thoughts?
ADJ: I think they’re going to happen in some form. I don’t know if the current form is what we’re going to see. I know they’ve been delayed by three months, at least initially until October 1st, but there’s a good chance they could be delayed even further, potentially even into 2018. I do believe that the bundles are going to have a very big impact in how onsite services are provided. Unfortunately for me, our hospital did not get involved in any portion of the bundle or the cardiac rehab incentive, but we are still preparing. Ascension is preparing as if the bundles are going to take effect and looking at ways to best utilize services.
From every conversation I’ve seen and heard, cardiac rehab is going to play a large part in that bundle, and I think, from personal experience, cardiac rehab can serve as a nice buffer to those individuals who are discharged to ensure that they are not going to get readmitted. Cardiac rehab can serve not only as the exercise in rehab portion, but the eyes in absence of the cardiologist. As the patients come into cardiac rehab, they can be watched and looked at for initial changes in their health or some initial problems that may be developing that could potentially lead to an admission. Those could be caught quickly and potentially prevent that readmission from occurring.
I know that one looks at ways to save money in these bundles and you look at potential programs getting cut. As part of our work with AACVPR, we’re looking at ways to ensure that cardiac rehab is looked at as that vital component in post-acute care because we’re going to have eyes and ears on these individuals on a regular basis. Ultimately, we’ll be able to catch issues that are arising much sooner, but also increases our ability to function through greater functional capacity, greater knowledge that will help them be better patients. That in itself, will help prevent readmissions as well, from making them less of a chance of having some adverse effects post discharge.
MA: Makes sense. The idea that you’re the eyes and ears of the hospital, particularly in the post-acute setting, is very powerful because I think a lot of readmissions could be caught just because the patients are better communicating with their providers. You, as a rehab center, act as the liaison to achieve that. That’s why there is that little bit of power in cardiac rehab.
ADJ: Especially for such a low-cost offering. Again, cardiac rehab in the scheme of things has not been a very expensive offering. So to prevent that readmission penalty, I think that it would be a very well-utilized service.
MA: Speaking about the cost of rehab, if you were to pitch CR to your administration, how much it costs and what the return of investment is. How would you pitch it?
ADJ: I think I would pitch that the cost to the administration is very low. It’s a system that’s very stable. Equipment costs are a capitalized item that are utilized for long-term so that the initial investment is really low and is maintained over the course of many years. Staffing is very minimal as compared to other services in the hospital. The site itself can really be placed in many places, both on-site and off-site of the hospital campus. I would really push the fact that cardiac rehab staff are able to see multiple diagnoses upon discharge and that those diagnoses are often at high-risk for readmissions.
By having our nurses and our exercise physiologists interacting with them on a regular basis, they are preventing what could potentially be a very high penalty, or high-cost readmission. By just having the service that really doesn’t cost a lot to offer, you’re saving money in the long-term. In the short-term you can make money based on how efficient your offerings are with your program and with the services you’re providing.
MA: What metrics do you think a rehab program would have to collect to show how they are delivering the level of care and showing a return on investment?
ADJ: I think you’re going to have to look at a couple main things. You’re going to have to look at the number of patients that are entering based on referrals and how many referrals are being received in total based upon the amount of discharges you get from the hospital based on services that are approved for cardiac rehab currently in the system. Then, when the patient enters, you have to look at adherence as well as various outcomes and measures including, Number-1, probably the most important factor is increases in functional capacity. How much are they improving from beginning to end.
Things like weight loss or blood pressure control are important but you’re not going to see as much of an impact from cardiac rehab on those measures as you would from functional capacity. That change in functional capacity is going to demonstrate how well they’re able to manage themselves outside of class and outside of the hospital. Therefore, you’re providing the administrators the ability to see that they are getting improvement and that you are providing benefit in the long run.
MA: So let’s transition a little bit to the future. How do you see CR evolving in the next five years compared to the last five?
ADJ: Well, the that’s scary because we’ve had so much change over the last five years. Change has come so quick that if we maintain this pace, it’s going to be very, very interesting to see how well cardiac rehab facilities are going to be able to keep up. I think you’re going to see a lot of focus on referrals. I think there’s going to be a significant increase in the number of referrals. We’re going to continue to see enhancements and improved operations and efficiencies in the referral systems. We’re getting better and have gotten better over the last few years, but those are areas that continue to improve.
I think you’re going to see changes into how facilities are offering the programs. You’re going to see a dwindling number of programs utilizing classes, shifting to more of an open-gym concept, but I do think that the most important change is going to be the institution of both a hybrid-type program (hybrid being partial in the gym and partial at a home facility) or home-based programs. At-home programs may be exclusively at home where they’re maybe managed by a cardiac rehab facility themselves or managed by a nurse who only works with home-based care.
These programs are going to be both a combination of monitored and unmonitored visits, and there’s going to be communications developed through reporting that’s going to be done both between cardiac rehab center and the patient, and the cardiac rehab center to the physician so that there’s a nice continuous chain of information being provided both from the patient themselves, but also from the cardiac rehab center back to the referring physician.
MA: In our experience, we’ve found that a lot of cardiac rehab centers today are so busy. Would they have the time to explore these other options like home-based rehab and so-on, particularly given that it’s not reimbursed today? How should a cardiac rehab be thinking about solutions? Should they pick long-term investments that they need to prepare for today, or should they wait to see how things are going to evolve?
ADJ: Yes, it’s true that technology is always ahead of government policy as far as being able to do things even though they are not reimbursed, and that’s unfortunate. I do think cardiac rehab programs in hospital systems in general, are going to need to see the advantage of home-based care and hybrid models as a wave of the future and to invest in them upfront. It may not be a large portion of their programming but it’s going to have to take a portion of their programming. The captive audience is so much greater if you’re able to include them into your offerings.
There’s inherent efficiency that can be developed in cardiac rehab programs that aren’t there now that would allow some additional time to be spent with these patients and providing some resources towards these kinds of programs. I do think that it should be in long-term planning and be a larger part of any program. For programs who are surrounded by more rural settings and need to provide better access for those patients who can’t get to them on a regular basis, finding a way to incorporate these new offerings into their daily workflows should be more of an urgent matter.
MA: In the last two years, what we’re seeing is programs increasingly turn to these home-based or hybrid approaches even though they’re not reimbursed. They also see the value of building on the experience in the cardiac rehab center. In addition to center-based exercises, they want to offer a home-based exercise program that patients can continue. Eventually, that leads to self-sustaining behaviors. These programs are treated as a nice compliment to center-based rehab, but in the long-term, based on what you’re saying, the goal would be to also offer it to patients who don’t do any rehab today, further address some of the issues like access and so-on.
ADJ: Completely. That’s ultimately going to have to be a goal of cardiac rehab and the well-being of the patient needs to be considered. There’s a large portion of individuals who are not going to be able to make it to a facility-based rehab program. There’s going to be models out there that are going to be developed, and really have been developed, that are going to allow exclusive home-based rehab through various monitoring and non-monitoring communications that are going to allow them to do their rehab remotely. There are some aspects that I think patients lose when they do home-based rehab in particular, for instance - the interaction with individuals who have the same medical history and have experienced some of the negative health changes that they have.
For those who are not going to be able to make it into a rehab facility, there’s got to be offerings available to them so that they can ensure that from a hospital perspective, they’re not going to come back, or at least the likelihood of them coming back is low, relative to a readmission due to an issue that develops post discharge.
MA: That’s a powerful concept. One last question for you. If you could make one legislative or policy change in cardiac rehab today, what would that change be and why?
ADJ: Oh, I’ve got 1-A and 1-B! 1-A would be the ability for advanced practice providers like nurse practitioners and PAs, to be able to supervise cardiac rehab, and pulmonary rehab for that matter. Currently, these functions must be done by a physician and it’s a very expensive endeavor for rehab facilities to have to pay these physicians to sit there and really be available just to respond to that rare emergency. It’s something that doesn’t occur very often but facilities are spending significant amount of money for an unreimbursed practice. I think that is something that needs to change.
1-B, and the second most important thing, would be to find a way for home-based rehab to be considered for reimbursement and finding a way to create that model that pays the rehab facility to offer somebody in the program to be able to spend time to monitor them on a regular basis and to communicate between the patient and the physician to ensure the safety. It ensures quality as well. If we could get the reimbursement up-to-speed with the ability that we have currently, I think we’d go a long way into capturing the number of patients we need to be successful and really make a dent in post-acute care resources.
MA: Well we hope that happens too, we’re excited by what the future holds!