Acute cardiac events such as myocardial infarction, heart failure, and intracoronary artery procedures affect over two million individuals in the United States each year and over half of these individuals are over the age of 65.1 Also common in older adults are cardiac surgical procedures such as coronary artery bypass and valve surgery.2 Advances in the treatment of cardiac events and surgical procedures have resulted in older and sicker patients surviving. 3, 4 These older patients are challenged with a difficult recovery after hospitalization due to the concomitant occurrence of comorbidity, frailty, and restricted activity during the hospital stay..5–7 The consequence is that older adults after cardiac events often require additional post-acute rehabilitation at a skilled nursing facility (SNF).
The rate of hospital discharges to SNF is steadily increasing in the Medicare population.8 Specifically for older cardiac patients, approximately 30% of myocardial infarction, 25% of heart failure, 11% of coronary artery bypass surgery, and 20% of valve surgery patients use SNF care.9 Medicare A reimburses 100% of SNF services for the first 20 days if a patient qualifies with a skilled need.10 Patients qualify if a physician certifies that they need either skilled nursing care (e.g., intravenous medication, extensive wound care) or additional physical, occupational, or speech therapy. SNF services are based on a geriatric rehabilitation model that enhances independence in mobility and activities of daily living. Skilled services include continuous nursing care, observation and assessment of the patient’s changing condition, ongoing assessment of rehabilitation needs and potential, therapeutic exercises or activities, and gait evaluation and training.10, 11 Physical and occupational rehabilitation services are delivered once per day.
Although these skilled services assist the patient in regaining functional abilities, other services are needed to assist patients and their families with specific cardiac rehabilitation to ensure optimal recovery. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommends the integration of cardiac specific rehabilitation components (exercise and education) into post-acute care to ensure safe and comprehensive cardiac care.1 For exercise, cardiac specific care includes risk stratification, monitoring the cardiac response to exercise, and endurance training. Categorization of patients into risk categories (low, intermediate and high) is important to understand the patient’s risk of ventricular arrhythmias and hemodynamic instability with exercise. Monitoring the cardiac response to therapy (exercise) is important to detect hemodynamic changes that indicate that a patient is not tolerating the therapy. Endurance training is important in both traditional SNF rehabilitation and cardiac specific care; but cardiac patients need to understand that exercise will not only improve their functional status, but also will improve their cardiac condition. Cardiac patients need a plan to continue training for cardiac health. Cardiac specific education also is recommended to ensure that patients and families are able to self-manage their chronic disease when they return home. Education on self-management of cardiac symptoms, (e.g. knowing what to do if they get short of breath with activity or have heart palpitations), survival management (e.g. knowing what to do if they get chest pain), and education on the importance of attending outpatient rehabilitation are important goals.1
The Skilled Nursing Facility Cardiac Care Model was developed to guide the understanding of how cardiac care of the SNF patient fits into the current cardiac rehabilitation model (Figure 1). Current cardiac rehabilitation includes acute inpatient services (referred to as Phase I and is not reimbursed by Medicare), sub-acute inpatient (referred to as Phase IB and is not reimbursed by Medicare), and outpatient (referred to as Phase II, begins 2–3 weeks after hospitalization for a cardiac event, and is reimbursed by Medicare).12 Phase IB cardiac rehabilitation programs have been developed and tested to address patients who need a longer rehabilitation program in an inpatient setting such as a SNF.12–14 The SNF Cardiac Care Model includes patient characteristics that are important to consider in determining eligibility for the cardiac care services delivered in the SNF. The patient characteristics related to successful rehabilitation and discharge home include illness severity, cognitive status, physical function, depression, pain, complications, comorbidity, and social support as these characteristics impact rehabilitation success.9, 15 Specific cardiac care to include during a SNF stay includes exercise (risk stratification, monitoring the cardiac response to exercise, and incorporation of endurance training) and education (management of cardiac symptoms, survival management, and discussion of outpatient cardiac rehabilitation).1 These cardiac care services are consistent with the goals and services delivered in traditional SNF care. The SNF Cardiac Care Model also incorporates the discharge destination of patients who use SNF care in order to highlight the trajectory of patients through the system. The purpose of this research is to describe the characteristics of patients in SNF following a cardiac event and the current cardiac care delivered during SNF and will include: 1) the demographics and characteristics of their condition, 2) the percent eligible to participate in cardiac rehabilitation, 3) the discharge destination, and 4) the current cardiac care delivered.