Referral Process Improves Cardiac Rehabilitation Participation Rates

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Referral Process Improves Cardiac Rehabilitation Participation Rates

< 1 minute read

Dartmouth Hitchcock Medical Center’s dedicated referral process translates to higher outpatient cardiac rehab participation rates.

The Issue

Despite well-documented benefits, the rate of referral to outpatient cardiac rehabilitation programs has remained low. We wanted to verify that our institution’s procedure for managing cardiac rehabilitation referrals met or exceeded the national average and if these referrals translated into outpatient participation. We aimed for 70% participation in alignment with the Million Hearts® initiative.

What We Tried

A registered nurse from our cardiac rehabilitation program works with providers from the Cardiovascular Medicine and Cardiothoracic inpatient teams, a mix of physicians, physician’s assistants, and advanced practice nurses, to identify all patients eligible for outpatient cardiac rehab. Our team is comprised of 2 registered nurses and 1 exercise specialist. The nurses take turns going to the inpatient unit and together these three staff run the outpatient program.

After identification, the nurse discusses risk factor modification, activity guidelines and the outpatient cardiac rehabilitation program with each patient. The nurse places referral for outpatient cardiac rehab in the electronic medical record and transmits it to the appropriate local cardiac rehabilitation program along with the discharge summary. Program staff then contact patients within two weeks of discharge to arrange enrollment.


DHMC achieves a cardiac rehabilitation participation rate over 80% that far exceeds the national average and the goal set forth in the Million Hearts® initiative. We refer over 1000 patients to over 30 hospitals. We found that longer wait times from hospital discharge to start of cardiac rehab were negatively correlated with participation rates (r=0.003). We address this by requiring a follow-up within two weeks from discharge, but this is an area for further study.

Our data found that the longer it takes for patients to start cardiac rehab, the lower participation rate (as seen in CR program “J” in the graph above).  The programs with the highest participation rates were able to get the patients in to their program quickly (CR programs D, DHMC, E and A).


The approach used at DHMC, which includes a cardiac rehabilitation nurse working with the inpatient cardiac services, should be considered by those programs wishing to improve referral rates.

Embedding a member of the cardiac rehabilitation team in the inpatient care environment is not a reimbursable service, the perceived benefit of this service to patients has been thought to outweigh its cost. Additionally, the increased revenue from successful referral to programs may offset the cost. The lessons learned in this program may be applicable in the nationwide quest toward achieving the Million Hearts® goal of 70% participation in outpatient cardiac rehab.

One area of potential opportunity is to create a formal tracking system for the thousands of patients discharged from our hospital and the status of their outpatient cardiac rehab referral.  This would require a complex system of collaboration among many hospitals.

One of the easiest things we can do is to share our data with other programs so that they can potentially make adjustments in their processes of getting patients enrolled earlier.

The feedback from the regional programs is that they are very satisfied with our referral process. They state that they appreciate the quick transmission of the cardiac rehab referral and discharge summaries as well as ease of contacting our facility.

The providers within DHMC are also extremely satisfied as we coordinate all inpatient and outpatient referrals for them and their patients.


Kristen Frechette, Terrence Welch, Sheila Conley

Organizational Background

Organization Name: Dartmouth Hitchcock Medical Center

Location: One Medical Center Drive, Lebanon, New Hampshire 03756, US

Organization Type: Hospital

Organization Model: Not Set