Cardiac rehabilitation and secondary prevention (CR/SP) services have proved effective for improving risk factor management and reducing morbidity and mortality among patients with coronary artery disease. As a result, CR/SP services are recognized as a standard of care for patients with cardiovascular disease (CVD).1–6 CR/SP services are provided through an interdisciplinary approach and include specific core components known to optimize cardiovascular risk reduction, foster healthy behaviors and compliance, reduce disability, and promote an active lifestyle for persons with CVD.7 Competent health care professionals from multiple disciplines are essential to the delivery of comprehensive CR/SP services that meet both patient needs and the requirements of a fluid health care environment. The purpose of the article is to update the previous statement of core competencies for CR/SP professionals,8 relate these competencies to the revised core components for CR/SP programs,7 reflect current expectations in providing CR/SP services,9 and integrate a core set of contemporary competency expectations recommended for all health care professionals.10
It is important to understand that defining competence, including specific competencies, is complex and dynamic. Professional competence is a multifaceted concept centered on the integration of core knowledge and skills into clinical practice, but also involving interpersonal skills, lifelong learning, and professionalism.11 Competencies reflect the legal, ethical, regulatory, and political influences on the practice of professionals in health care that are defined as essential for a practitioner within a specific health discipline. Core competencies are used to define a set of measurable indicators required for minimal expectations for performance within a health discipline. Core competencies are used as a framework to align health care providers, educators, students, consumers, and payors with defined expectations for providing care in accordance with evidence-based standards, performance measures, and quality outcomes.12
GENERAL CORE COMPETENCIES FOR HEALTH CARE PROFESSIONALS
The Institute of Medicine (IOM) established quality initiatives designed to help improve quality of care and patient safety.13 Since skilled and knowledgeable health care professionals are needed to implement the transformation of health systems to advance quality, the Health Professional Education Summit was convened to develop a core set of competencies.10 These competencies were developed to address shifts in the US patient population resulting in the patients we serve becoming more diverse, older, and often with numerous comorbidities. The overarching vision from the IOM committee was for educational programs to incorporate the following in their educational and training programs:
All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.10(p45)
Table 1 illustrates the core competencies that all health care professionals should possess, regardless of their discipline, as proposed by the committee convened to meet the needs of today's health care environment.10 These essential core competencies are the basis on which specific core competencies can be built for all health care professionals working in CR/SP programs.
CORE COMPETENCIES FOR CR/SP PROFESSIONALS
Program core components define specific information and skills necessary to provide evidence-based care in CR/SP programs.7 These include comprehensive cardiovascular patient assessment; management of blood pressure, lipids, diabetes, tobacco cessation, weight, and psychological issues; exercise training; and counseling for psychosocial, nutritional, and physical activity issues. This evidence-based document provides the framework for defining core competencies for CR/SP professionals with suggested means for assessment. As previously recommended, provision of care is optimally provided through a case management function, which involves coordination of an interdisciplinary treatment plan.8 Health care professionals involved in providing CR/SP services come from multiple health disciplines, such as medicine, nursing, exercise physiology, physical therapy, clinical nutrition, psychology, social work/counseling.
The American College of Cardiology Foundation, American Heart Association, and American College of Physicians described a curriculum for developing competence among all health care professionals involved in the prevention of CVD.14 Section 16 of that publication specifically addresses recommended knowledge for cardiac rehabilitation and secondary prevention of CVD. The document defines a need for shared responsibility among multiple health care professionals in the prevention of cardiovascular morbidity and mortality. Opportunities for educational resources are critical to ensure the acquisition and maintenance of competence in cardiovascular risk-reduction strategies resulting from expanding knowledge in the field of CR/SP. It is important to acknowledge that each CR/SP health care professional may not necessarily achieve all areas of competencies. Consequently, it is the implementation of the case management approach utilizing the skills and competencies of the multidisciplinary CR/SP team, which will facilitate improved outcomes as measured by requisite studies of morbidity and mortality data.
Table 2 provides recommendations for core competencies in knowledge and skills for CR/SP professionals within each component of care. The organization of core competencies in this systematic approach accomplishes multiple goals. First, it identifies knowledge and skills that are important for professionals working in these programs. Second, it defines appropriate evaluation of skills and knowledge that should be assessed on the basis of professional training, education, certification, or licensure for professionals on the multidisciplinary CR/SP team. Third, it provides guidance to academic programs that prepare students to enter the field of CR/SP. Finally, these core competencies are incorporated into the AACVPR program certification process.15
These core competencies were developed to provide a comprehensive CR/SP program that is consistent with the recommended core components for CR/SP programs.7 The expectation is that 1 single heath care professional does not possess all of the core competencies. Rather, each member of the multidisciplinary CR/SP team, on the basis of education, training, and certifications or licensure, contributes certain core competencies to the team and, together, the team will possess many or all of the core competencies.
We acknowledge that this comprehensive list of core competencies may present challenges for CR/SP programs that are smaller or operate with limited access to resources. Therefore, these core competencies represent the ideal and should be viewed as a goal for all programs to strive to achieve through innovative programming and accessing available resources relevant to the individual CR/SP program.
1. Suaya JA, Stason WB, Ades PA, Normand SL, Shepard DS. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009; 54:25–33.
2. Lavie CJ, Thomas RJ, Squires RW, Allison TG, Milani RV. Exercise training and cardiac rehabilitation in primary and secondary prevention
of coronary heart disease. Mayo Clin Proc. 2009; 84:373–383.
3. Wenger NK. Current status of cardiac rehabilitation. J Am Coll Cardiol. 2008; 51:1619–1631.
4. Williams MA, Ades PA, Hamm LF, et al. Clinical evidence for a health benefit from cardiac rehabilitation: an update. Am Heart J. 2006; 152:835–841.
5. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention
of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation [erratum in Circulation. 2005;111: 1717]. Circulation. 2005; 111:369–376.
6. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agencies for Health Care Policy and Research, and the National Heart, Lung, and Blood Institute. AHCPR publication No. 96-0672; October 1995.
7. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention
programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev. 2007; 27:121–129.
8. Southard DR, Certo C, Comoss P, et al. Cardiac core competencies working group. Core competencies for cardiac rehabilitation professionals. J Cardiopulm Rehabil. 1994; 14:87–92.
9. American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention
Programs. 4th ed. Champaign, IL: Human Kinetics Publishers; 2004.
10. Greiner A, Knebel E; Institute of Medicine (U.S.). Committee on the Health Professions Education Summit. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
11. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002; 287:226–235.
12. Verma S, Paterson M, Medves J. Core competencies for health care professionals: what medicine, nursing, occupational therapy, and physiotherapy share. J Allied Health. 2006; 35:109–115.
13. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
14. Bairey Merz CN, Alberts MJ, Balady GJ, et al. ACCF/AHA/ACP 2009 competence and training statement: a curriculum on prevention of cardiovascular disease: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Competence and Training (Writing Committee to Develop a Competence and Training Statement on Prevention of Cardiovascular Disease). J Am Coll Cardiol. 2009; 54:1336–1363.
15. American Association of Cardiovascular and Pulmonary Rehabilitation. The AACVPR Program Certification page. http://www.aacvpr.org/Certification/tabid/63/Default.aspx
. Accessed January 20, 2010.
16. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revisions 2006. A scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006; 114:82–96.
17. Shumaker SA, Ockene JK, Riekert KA, eds. The Handbook of Health Behavior Change. 3rd ed. New York, NY: Springer Publishing Company; 2009.
18. Thomas RJ, King M, Lui K, et al. Writing group for the ACC/AHA Task Force Members. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention
services. J Cardiopulm Rehabil Prev. 2007; 27:260–290.
19. National Heart, Lung, and Blood Institute (NHLBI) Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. NIH Publication No. 98-4083, September 1998. http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf
. Accessed January 19, 2010.
20. National Heart, Lung, and Blood Institute (NHLBI) Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication No. 00-4084, October 2000. http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
. Accessed January 19, 2010.
21. Smith SC, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention
for patients with coronary and other atherosclerotic vascular disease: 2006 update; endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006; 113:2363–2372.
22. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine position stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009; 41:459–471.
23. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Institutes of Health Publication No. 04-5230. August 2004. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
. Accessed January 8, 2010.
24. Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D. Call to action and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. J Cardiovasc Nurs. 2008; 23:299–323.
25. Appel LJ, Brands MW, Daniels SR, Karanja N, Elmer PJ, Sacks FM. Dietary approaches to prevent and treat hypertension. A scientific statement from the American Heart Association. Hypertension. 2006; 47:296–308.
26. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals. Part I: blood pressure measurement in humans. A statement for professionals from the Subcommittee of Professional Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005; 45;142–161.
27. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002; 106:3143–3421.
28. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diab Care. 2010; 33(suppl 1):S62–S69.
29. Sigal RJ, Kenny GP, Wasserman DH, Casteneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes. A consensus statement from the American Diabetes Association. Diab Care. 29:1433–1438.
30. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription. 8th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010.
31. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick reference guide for clinicians. Rockville, MD: US Dept of Health and Human Services. Public Health Service; April 2009.
32. American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Cardiac Rehabilitation Resource Manual. Champaign, IL: Human Kinetics Publishers; 2006.
33. US Department of Health and Human Services. 2008 physical activity guidelines for Americans. http//www.health.gov/PAGuidelines
. Accessed January 21, 2010.
34. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000; 32(9)(suppl):S498–S504.
35. Thompson PD, Buchner D, Piña IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003; 107:3109–3116.