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Community-Based Cardiac Rehabilitation

A YMCA Model

Hutchinson, Kathy M.S.

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ACSM's Health & Fitness Journal: November 2006 - Volume 10 - Issue 6 - p 21-27
doi: 10.1249/01.FIT.0000252521.36994.eb
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Cardiovascular disease is the number one killer in the United States. In this country, more than 71 million people have some form of heart disease (5) with someone dying from it every 35 seconds (6). Commonly thought of as a man's disease, we must remember that women and minorities suffer as well. We often think of breast cancer as women's greatest health risk, a legitimate concern. However, whereas 1 in 30 women dies of breast cancer, 1 in 2.5 women will die of heart disease or stroke (7). Unfortunately, most women are unaware of these data. In 2003, the American Heart Association (AHA) surveyed 1,000 women asking, "What is the greatest risk to women's health (10)?" Only 13% answered cardiovascular disease. The need for effective exercise and lifestyle modification programs to impact these statistics is clear. To some extent, this need is being met by YMCAs around the country, where successful exercise-based cardiac rehabilitation (CR) programs are being offered. In the future, community-based organizations may be the key in meeting the needs of the millions of cardiac patients in the United States.

The Effects of Cardiac Rehabilitation

Exercise-based CR programs that include lifestyle modification have been shown to decrease mortality from cardiovascular disease by 20% to 25% (2). In the AHA's revision of their 1994 Scientific Statement on Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease (8), lead author Arthur Leon, M.D., states that the exercise component of a CR program improves

  • functional capacity
  • blood vessel function
  • cardiovascular risk factors
  • coronary blood flow
  • electrical stability (decreasing the risk of fatal arrhythmias) and reduces
  • the risk of blood clots
  • cardiac work
  • oxygen demand

The success of CR is well established. Unfortunately, only 10% to 20% of the millions of eligible patients actually participate each year (8). Many physicians neglect to emphasize the importance of CR, whereas many patients are unable to access programs because of time constraints or motivational reasons as well as geographical and financial limitations (4). Community-based organizations such as the YMCA can impact these obstacles by working to educate the medical community and, with their strong history in fitness and behavior modification, impact patient's personal barriers (time and motivation). With numerous locations around the country, geographical accessibility is impacted and financial assistance for those who qualify is offered.

Cardiac Rehabilitation-The Basics

According to the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), CR programs "are designed to decrease morbidity and mortality and improve a variety of clinical and behavioral outcomes, including quality of life. This is accomplished through a medically supervised exercise as well as intensive lifestyle interventions and health education" (2). Accordingly, patients who participate can then assume the responsibility of self-care and maintenance of their disease.

Traditionally, CR has been divided into four phases. However, in response to changes in the health-care system during the last 15 years, CR programs have changed as well. The sequence has remained the same, but the phase structure has been streamlined. AACVPR describes this new continuum of care for secondary prevention as follows (2):

  • Inpatient CR (previously referred to as Phase I) (1)
    • The length of stay is an average of 3 to 4 days.
    • An R.N., exercise physiologist, or occupational therapist (who already works in the hospital unit) will focus on "survival teaching" (2). Integrated with progressive activity, patients are taught the "do's and don'ts" (2) of their recovery and recognition of signs and symptoms and instructed on their medication.
  • Early-outpatient CR (previously referred to as Phase II) (1)
    • Rehabilitation starts 1 to 2 weeks after the event and lasts 6 to 8 weeks (depending on insurance coverage).
    • Exercise is electrocardiogram (ECG) telemetry monitored.
    • Risk-factor reduction is accomplished with education and lifestyle modification counseling specific to the individual patient.
  • Maintenance and Follow-up (previously referred to as Phases III and IV, respectively) (1)
    • Rehabilitation starts within 2 to 3 months after the event.
    • Program is ongoing. Patients may remain in the program for months or years.
  • Maintenance
    • Continued long-term supervised/non-telemetry-monitored exercise at hospital site or community exercise facility (YMCA, Jewish Community Center, or commercial gym). Instantaneous ECG monitoring may be available.
    • Lifestyle modification compliance is monitored by the staff during onsite visits to supervised maintenance class.
  • Follow-up
    • The patient exercises independently at home, at a commercial gym, or community center.
    • The patient has access to continuing education through rehabilitation program or hospital wellness classes.
    • Compliance is monitored through telephone calls, emails, or other predetermined technique.
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YMCA Cardiac Therapy

There are more than 200 YMCAs in the United States offering exercise-based CR programs called YMCA Cardiac Therapy (YCT). Some simply offer follow-up programs to medically supervised CR, whereas others offer early-outpatient and maintenance classes as well. The YMCA of the USA provides guidelines (3) which follow the established recommendations of AACVPR. However, The YMCA of the USA allows local programs to make changes to fit their individual needs or incorporate recommendations from the American College of Sports Medicine (ACSM) and the AHA and still refer to the program as YCT.

YMCA Cardiac Therapy Programs

The program description that follows is based on the YCT program at the Marin YMCA, just north of San Francisco.

Maintenance Program

There are five components to the Marin YCT Maintenance program: supervised exercise, stress reduction, social support, risk-factor education, and individualized reviews. The supervised exercise is offered three times per week in a group format, rather than using multiple exercise devices in a serial manner, as seen in most hospital settings. Considering their unique needs, a specially trained group exercise instructor leads the group through a traditional low-impact aerobics class. After a warm-up, class members perform 20 to 25 minutes of low-impact aerobics, 10 to 15 minutes of weight training using hand weights, 10 minutes of flexibility training, and 5 minutes of relaxation (stress reduction). Members with orthopedic limitations, claudication, or balance problems complete their cardiovascular exercise on a cycle ergometer set up in the same room. Using the physician's recommendation for exercise intensity, the staff advises the patient to pedal at a rate consistent with achieving that goal. Patients are closely supervised to ensure proper exercise intensity. These patients then join the rest of the class for weight training and relaxation. Led by the instructor, patients take their own heart rates throughout class, whereas the CR staff supervises members, monitors blood pressure, helps members check heart rates, and watches for signs of poor exercise tolerance.

Along with exercise and stress reduction, social interactions are encouraged and supported rather than considered disruptive. Conversations center on getting to know new friends or catching up with longstanding ones, and new connections are often made based on common medical conditions. Other forms of support come from the participation of spouses, who help encourage and motivate the cardiac patient, and biannual gatherings where members can spend quality time developing friendships with fellow members and staff.

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Most CR programs offer brief lectures on a regular basis to educate patients on the risk factors for cardiovascular disease. Alternatively, patients in the Marin YCT program prefer to read a take-home newsletter that is published by the director on a quarterly basis. YCT newsletters provide information about risk factors for cardiovascular disease, common cardiac medications, general nutrition and weight loss, injury prevention, and much more. Patients' birthdays are listed, and patients with perfect attendance are given emphasis. Patients' follow-up questions and comments regarding the information provided in the newsletter are handled individually.

Finally, individualized reviews are completed for each patient. This allows the staff to spend intensive one-on-one time with each patient to maximize their success in the program. When starting the program, a risk-factor profile is determined for each patient. Goals are discussed and set. The staff then tracks their progress throughout the year, and on an annual basis, the original paperwork is reviewed with the patient. Questions are answered, clarifsications are made, and new goals are established.

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Follow-up Program

The follow-up program at the Marin YMCA includes the same risk-factor education program, individualized reviews, and social support, but the patient exercises independently. Patients who have graduated from the maintenance class or are medically stable and motivated to exercise on their own from the time they start the program meet with a CR staff member to design an individualized exercise program. This is where a large fitness facility can be fully utilized. Patients in the follow-up program take classes in the pool to treat orthopedic problems, take yoga or Tai Chi classes for stress reduction, or work out in the fitness center to accomplish their cardiovascular and strength training needs.

Unlike early-outpatient programs, where the number of sessions is most often determined by insurance coverage, maintenance and follow-up programs are ongoing. Because third-party reimbursement is not an option for these types of programs, patients self-pay and therefore determine the length of time they participate. Many patients in YCT treat the program as a lifetime commitment.

Staffing and Equipment

Staff

The staff working in a community-based CR program are the same as those working in a hospital setting and include registered nurses, exercise physiologists, and other nutrition, diabetes, or exercise professionals. The Marin YCT program employs critical care nurses from local hospitals to work on their days off. Currently, the only exercise physiologist is the full-time director. Often, nutrition and diabetes professionals volunteer their time to work with YCT patients by giving lectures, writing articles for the newsletter, or talking with patients one-on-one during class time. Medical direction at the Marin YMCA is provided by one of the local hospitals, but the physician is not readily available during class time. Therefore, emergency medical services (EMS) are relied upon for all emergencies.

Other than the full-time director, all staff work part time in YCT. Nurses who work full time in hospital settings seek out jobs in the YMCA program because they are inspired by the YCT members. The stress that nurses endure while caring for patients during the most critical stages of their disease (i.e., those who are recovering from having a heart attack or who have undergone coronary revascularization via angioplasty or bypass surgery) is somewhat relieved by working in YCT. These professionals are encouraged by seeing people recover and go on to live productive lives. Furthermore, they are able to take accurate information about recovery back to their regular jobs and convey it to hospitalized or recently discharged patients being treated for cardiovascular disease.

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Figure

Equipment

Emergency equipment is stored on a traditional crash cart, including a manual defibrillator, oxygen tank, intravenous equipment, blood pressure cuffs, and emergency drugs according to the medical director's standing order. A manual defibrillator is a traditional defibrillator that requires the user to read the ECG and determine the appropriate action. A manual defibrillator is used in YCT, rather than an automated external defibrillator, so that ECG strips can be generated when needed. The staff is Advanced Cardiac Life Support (ACLS) certified, so all know how to respond in an emergency using this type of equipment. Furthermore, new arrhythmias have been identified by YCT staff while obtaining an ECG strip in response to patient symptoms. The new biphasic defibrillators currently on the market are excellent products for this type of environment.

Storage in a multiuse gymnasium may be limited, so adjunctive equipment is carried on the cart and may include a drug book, a glucometer to rapidly assess blood glucose, juice to treat hypoglycemia, music for relaxation, and a wrench to adjust bike seats.

Documentation of patient histories, compliance, and achievement in the program is done using standardized forms from AACVPR (2) or those developed to meet specific needs of the program. The types of forms used in the Marin YCT program include:

  • physician referral
  • intake-personal information, medical history, risk-factor assessment
  • informed consent/release of liability
  • release of medical records
  • progress notes
  • annual clinical review
  • patient progress/incident reports
  • daily exercise record
  • emergency cart checklist

AACVPR also provides examples of standing-order protocols used for both hospital-based and freestanding CR programs.

Collaborations

Working closely with local hospitals is vital to ensuring a successful community-based program. Cardiac patients start either YCT at the Marin YMCA after going through the early-outpatient program at the local CR center or non-exercise-based CR program at one of the other local hospitals. The relationship between YCT and these hospital-based programs ensure smooth transitions for patients between the hospital and community settings and minimal interruptions in care.

While developing a community-based program, formalizing partnerships with one or more hospitals is one way to guarantee a consistent referral source. Partnerships can include medical direction and support with equipment and supplies from the hospital, whereas the community-based organization offers its facilities, programs, and, if applicable, financial assistance for patients. Presenting a sound plan that follows AACVPR recommendations for programming and outcomes to local physician groups also is a way to develop relationships that will further support your program. In addition to presenting a program plan, providing information on the physician's role in CR is crucial. In general, the rates at which physicians refer patients to CR are quite low (8). It is up to the CR director to inform health-care workers on the success of CR and encourage practitioners to refer their patients. Speaking to physician groups also is an opportunity to discuss women and cardiovascular disease. In a study published in Circulation (9), less than 1 in 5 physicians recognized that, each year, more women than men died of heart disease. Low referral rates and a misunderstanding of women and cardiovascular disease, along with a patient's personal reasons for the lack of participation in CR, all contribute to the underutilization of CR programs. Educating physicians and other health-care providers on the importance of CR and their role in ensuring that patients attend not only will enhance the referral base to your program but also, more importantly, improve patient care.

Challenges and Successes

Challenges

There are challenges to operating a YCT program. Because the program is not in a hospital setting, it is often difficult to communicate with patients' doctors. YMCA CR staff must have excellent assessment skills and the support of their local EMS. Staff knowledge of when and how to activate EMS is essential. When exercise-related signs or symptoms arise and resolution is not immediate, 911 may need to be called. YCT staff treat patients with on-site medical equipment and medications (according to ACLS protocols and standing orders provided by the medical director), until EMS arrives with further treatment options and transport.

The use of a gymnasium and a group exercise format allows for many participants at one time. When appropriately staffed (one staff member per 10 participants), a program with only two classes per day can still have as many as 100 members. Although able to handle a class of 50 participants at a time, on any given day, the number of patients who actually attend a YCT class at the Marin YMCA averages 30. Classes are therefore staffed with three to four nurses/exercise physiologists, plus an aerobics instructor. Although this provides a way to impact a large community, individual education can be difficult, particularly with regard to weight loss. As most fitness professionals know, successful weight loss often only occurs when individual attention is paid to the patient. When staff is responsible for supervising up to 10 program participants at a time, it is difficult to have in-depth conversations during class to influence meaningful change.

One final difficulty in YCT is that the program is offered in a multiuse facility. Program space is often limited and is difficult to book for more than one hour at a time. Because a conditioning regimen of cardiovascular exercise, full-body strength training, and valuable stress reduction cannot be completed in that time, modifications must be made. To complete a full-body strength training workout, instructors lead the group through exercises working different muscle groups each day (e.g., biceps, triceps, quadriceps, and gluteals on Monday; pectoralis, latissimus dorsi, and abductors/adductors on Wednesday). Furthermore, members are led through different methods of stress reduction (visualization, meditation, progressive relaxation, etc.) during the final five minutes of class-one type is chosen per day. Members are then encouraged to practice on their own.

Successes

Even with the challenges encountered, YCT is successful in many ways. Utilizing a YMCA facility and its fitness center allows for the use of a larger variety of equipment to facilitate an exercise prescription (e.g., a pool to help patients with the orthopedic limitations).

Although insurance coverage is traditionally not an option for maintenance or follow-up programs, patients in need can apply for financial assistance to help pay for a potentially lifesaving program. As a nonprofit organization, the "YMCA memberships and programs are open to everyone. To the extent possible, financial assistance is made available to those in need, so they are not excluded from YMCA programs (11)." About 10% of the YCT patients at the Marin branch receive financial assistance. The remainder pays out of pocket for the program. Most often, patients choose to come to the YMCA because it is closer to their home and it is more affordable. A general membership for the Marin YMCA includes use of all facilities, group exercise classes, babysitting services, and discounted rates on extra programs. YCT members receive the general membership in addition to the CR class for a rate that is less expensive than other CR programs in the area.

Cardiac patients in YCT are referred to as members rather than patients. While in the program, members self-chart their progress and learn a new sense of body awareness. This effort builds independence, improves quality of life, and allows the member to feel normal and healthy again. Anecdotal evidence of improved risk factors and other cardiac markers (i.e., ejection fraction) is noted because members enjoy coming to class and have excellent attendance.

AACVPR describes the positive benefits of aggressive risk-factor modification to include delaying the progression of disease, reducing risk of reinfarction, and reducing risk of death (2). One risk factor most frequently impacted by YCT staff is hypertension. When inappropriate trends are noticed, the staff counsel often reluctant members to seek medical attention. The staff use "consistent and repeated verbal instructions and explanations" (2) to persuade members to contact their health-care providers. Members return after visiting their physician with noticeable changes to their blood pressure and appreciation for the staff insisting that they seek treatment.

The social support within the group is probably the single greatest contributor to adherence, with retention rates in the Marin YMCA program as high as 98%. Average member tenure is approximately 12 years, with some members participating for as long as 18 years. One member participated in the program for 27 years before moving out of the area.

Conclusion

In light of the increasing numbers of people in the United States diagnosed with cardiovascular disease, making exercise-based CR more accessible and affordable is critically important. Many YMCAs around the country have successfully met this need by offering traditional CR programs in their multiuse facilities. YMCAs provide programs and services that are successful and cost-effective, and they help the community participate by providing financial assistance when needed.

References

1. Robertson, L., K. Reel, R. Crist, et al. (Editors). American Association of Cardiovascular & Pulmonary Rehabilitation Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 3rd ed. Champaign: Human Kinetics, 1999, pp. viii.
2. Robertson, L., A. Rogers, A. Ewing, et al. (Editors). American Association of Cardiovascular & Pulmonary Rehabilitation Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign: Human Kinetics, 2004, pp. 2, 6, 8, and Appendices A-X.
3. YMCA of the USA. Cardiac Rehabilitation Programs in YMCAs. Statement of the YMCA of the USA Medical Advisory Committee. Unpublished document. Chicago, 2004, pp. 1-2.
4. Brehm, B. Recovering from heart attack or surgery: importance of cardiac rehabilitation. Fitness Management February 2001, p. 38.
5. Thom, T., et al. Heart disease and stroke statistics-2006 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 113:e85-e151, 2006. Available at: http://circ.ahajournals.org. Accessed May 6, 2006.
6. Centers for Disease Control. Heart disease and stroke: the nation's leading killers. Available at http://www.cdc.gov/nccdphp/publications/aag/cvh.htm. Accessed June 14, 2006.
7. American Heart Association. Understand your enemy: quick facts. Available at http://www.goredforwomen.org/love_your_heart/quick_facts.html. Accessed May 22, 2006.
8. American Heart Association. Doctors should encourage cardiac rehab programs. Available at http://americanheart.org/presenter.jhtml?identifier=3028355. Accessed March 6, 2006.
9. American Heart Association. Women's heart risk underestimated by doctors, resulting in less preventive care than in men. Available at http://americanheart.org/presenter.jhtml?identifier=3028550. Accessed March 6, 2006.
10. American Heart Association. Facts about women and cardiovascular diseases. Available at http://www.americanheart.org/presenter.jhtml?identifier=2876. Accessed April 20, 2005.
11. YMCA of San Francisco. Financial statement. Available at http://www.ymcasf.org/Marin/about.html. Accessed August 2006.
Keywords:

Cardiovascular disease; Exercise; American Association of Cardiovascular and Pulmonary Rehabilitation; Risk factor; Nonprofit

© 2006 American College of Sports Medicine