CIRCLE OF CARDIAC CARE:
A TRANSITIONAL CARE APPROACH
Ana Mola, MA, RN, ANP-BC, CTTS, Program Director, Joan and Joel
Smilow Cardiac & Pulmonary Rehabilitation and Prevention Center
The Patient Protection and Affordable Care Act, also known as
the healthcare reform bill, promotes greater efficiencies and timely
patient access to outpatient services, including outpatient cardiac
rehabilitation. Many patients with cardiopulmonary problems
require home care, including nursing and physical therapy, after
discharge from acute hospitalization or inpatient cardiopulmonary
rehabilitation units. The Rusk Institute of Rehabilitation Medicine
Cardiopulmonary Rehabilitation and Prevention Center has
partnered with the Visiting Nurse Service of New York (VNSNY)
to put this new legislation—passed in March 2010—into practice
for the enhancement of the patient’s transition from inpatient
cardiopulmonary services to community reintegration.
Patients are not always ready to begin a comprehensive
outpatient program in cardiac or pulmonary rehabilitation right
after discharge from the hospital. The partnership between Rusk’s
Cardiopulmonary Rehab Center and VNSNY was organized to
bridge individualized, patient-centered therapy services from
inpatient settings to the community. The professional teams of
both Rusk and VNSNY are transdisciplinary, with physicians,
nurses, physical and occupational therapists and mental health
counselors collaborating to enhance the patient’s transition.
Through the partnership, the individualized physical activity
treatment plan developed and implemented in the hospital is
communicated to the VNSNY team to ensure its continuation
with the patient, thereby increasing his or her ability to perform
the activities of daily living. Dr. Jonathan Whiteson, the medical
director of the Rusk Cardiopulmonary Rehabilitation and
Prevention Center stated, “With this seamless transition of care,
both hospital and community clinicians can implement the needed
services that ensure world-class care. The teams are focused on
keeping patients healthy and functional in the community, with an
emphasis on quality of life.”
The teams are focused on keeping patients
healthy and functional in the community, with an
emphasis on quality of life.
The partnership began over two years ago as VNSNY selected
care teams in the borough of Manhattan to participate in the
pilot patient program. A referral process was established so
that consistent, accurate information would be communicated
between participating Rusk patients and VNSNY members upon
patient discharge. The Rusk Cardiopulmonary Rehab team
provided nine hours of cardiopulmonary rehabilitation in-service
training to the VNSNY Manhattan team, and then more than fifty
VNSNY nurses and therapists spent a half day observing at the
Rusk Cardiopulmonary Rehab program to gain greater insight
into the inpatient care of cardiopulmonary patients. Ongoing,
collaborative meetings between Rusk and VNSNY to review
patient cases ensures adherence to VNSNY standards and overall
quality of case management. Today, the partnership program has
expanded to Brooklyn and Queens.
One of the goals of the partnership program was to educate
VNSNY staff and encourage them to speak to the patient’s
providers as a way of enhancing the standard of care for referred
patients. Nationally, the current referral rates for cardiac patients
to outpatient cardiac rehabilitation programs is between 25%
and 30%. This circle of cardiac care—a transitional approach
encompassing the patient’s journey from hospital to home to
outpatient cardiac rehabilitation—begins to address the challenge
of the Affordable Care Act and its mandate to promote “greater
efficiencies and timely access to outpatient services.”
PRESORTED
FIRST CLASS MAIL
U. S. POS TAGE
PAID
NEW BRI TAIN, C T
PERMI T NO. 103
REHABILITATION THAT FOCUSES ON THE WHOLE PERSON
RUSK INSTITUTE OF REHABILITATION MEDICINE
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