Improving Patient Recovery Through Cardiac Rehab

4 minute read

Improving Patient Recovery Through Cardiac Rehab

< 1 minute read

Penn State Health St. Joseph started implementing cardiac rehab immediately after hospital discharge

The Issue

With the help of a supportive and progressive cardiologist as our medical director, the outpatient program started in 1978, work that continues today. We wanted to provide patients with the best care by starting rehab at the right time. However, there is limited research on the ideal time to start cardiac rehab. Without research to guide action, the team decided to start rehab immediately following hospital discharge because we felt there was no benefit in waiting.

What We Tried

We worked with providers (ex., surgeon, cardiologist, primary care providers), case management team and cardiac rehab team to determine qualifying criteria. As stated by CMS Regulations and Guidance, for patients to be able to start cardiac rehab immediately upon discharge after open heart surgery and/or myocardial infarction or percutaneous coronay intervention (MI/PCI), the patient must:

  • be medically stable to go home,
  • not need any visiting nursing services,
  • have transportation to the cardiac rehab program, and
  • have insurance coverage with no delay for authorization.

The interdisciplinary team rounds daily on our patients in the hospital to address any potential issues or concerns for a safe discharge to home with early enrollment into the cardiac rehab program. All patients who meet the criteria are given their outpatient cardiac rehab appointment when they leave the hospital. Many will start within 3-5 days, depending on scheduling.

On our team, we have three registered nurses (RN) and one clinical exercise physiologist. Penn State Health St. Joseph started therapy upon discharge. Cardiac rehab staff assessed wounds and checked vitals at therapy sessions, using session attendance as a way to get patients out of the house and physically active. Patients attending therapy do not have visiting nurse care.

Staff spend at least 60 minutes (but sometimes more than 90 minutes, depending on needs) with the patient during the first visit conducting a thorough assessment and reinforcing home care education. The nurse in the program will assess wounds, provide basic wound care, educate the patient/family and call the surgeon’s office with any concerns, if needed. The program worked through some transportation issues with BARTA, the local public transportation system, to provide door-to-door services in a very timely fashion. Staff complete the application for the patient and send it in to BARTA for immediate processing. Additionally, our finance office meets with patients who have financial or insurance concerns to work with getting them coverage, including charity care.

The intimate nature of a small community hospital makes it easier to communicate with the necessary physicians and staff. Communication is key to making this model work with limited resources. This project had full support from the provider’s office. They are immediately available to answer any patient concerns.

We recently celebrated our 40th anniversary and National Cardiac Rehab Week.


The patients are doing great. They are recovering faster physically, emotionally and mentally. We are using the cardiac rehab registry from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) data submission and comparison with national outcomes data. We are always looking for ways to improve our program.

There has been significant program growth in the past two years. Renovations and expansion are planned to support this growth. The full-time outpatient cardiac rehab staff were recently certified as Wellcoaches.


You need to have staff who are passionate about what they do, who aren’t afraid to step up and work hard to find the necessary resources. They should be knowledgeable about their profession so they can eloquently speak to every level, both provider and patient about what we do and how we can impact our patients lives. We work with the staff to create an environment where they can function and provide the care that makes all of us proud.

To learn more about cardiac rehabilitation, or cardiac rehab, to go the Million Hearts campaign to access tools and resources. Heart disease, stroke and other cardiovascular diseases kill over 800,000 Americans each year, accounting for one in every three deaths. It’s the nation’s number one killer among both men and women and the leading cause of health disparities across the population. To address this issue, the U.S. Department of Health and Human Services (HHS) established Million Hearts, a five-year initiative co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS).

Organizational Background

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