1. Cardiovascular Rehabilitation and Secondary Prevention – Why is it so important?

2. 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”

3. 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!

4. 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 benefit 9

5. 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

6. 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.

7. What policy do we have?  http://www.healthnetworks.heal th.wa.gov.au/docs/1405_CRSP _Pathway_Principles_WA.pdf http://www.healthnetworks.heal th.wa.gov.au/docs/1405_CRSP _Pathway_Principles_WA.pdf plus  Quick Reference Guide and Consumer information sheet …insert link

8. CRSP Pathway Principles

9. Part 1: Pathway overview Part 2: More detail – colours corresponding to part 1

10. 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

11. ● 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%2 0assessment%20tool.pdf http://www.heartonline.org.au/SiteCollectionDocuments/Cardiac%20rehab%20needs%2 0assessment%20tool.pdf

12. ▲ 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

13. ♦ 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.

14. ♥ 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 Exercise Community 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 Change Specialised 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

15. ©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-up 2.Supports titration of medications 3.Liaises with GP 4.Refers to physio for exercise 5.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.

16. ©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

17. ©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 factors 2.Referral to dietitian and QUIT program 3.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.

18. ©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 factors 2.Follow-up with clinical psychologist 3.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.

19. ©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.

20. ©2014 National Heart Foundation of Australia GP assesses patient, determines lower complexity cardiac condition and refers to:  Practice Nurse  Cardiac Rehabilitation Coordinator  Cardiologist 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

21. What’s the Heart Foundation role in improving Cardiac Rehabilitation in Australia? What resources are available? http://www.heartonline.org.au

23. http://www.heartfoundation.org.au/information-for-professionals/Clinical-Information/Cardiac- rehabilitation/Pages/default.aspx

25. 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

26. Thankyou If you have feedback or any concerns, about the content of this presentation or supporting materials please email the Cardiovascular Health Network on healthpolicy@health.wa.gov.au healthpolicy@health.wa.gov.au