Geisinger is a world-class health system in Pennsylvania with 10 hospital campuses, more than 130 clinic sites and more than one million patients served annually. Its health plan covers more than half a million members.

THE PROBLEM

As a rural health system stretching across a broad geography, transportation can be a barrier to patient engagement. Geisinger strives to make better health easy, but it can be challenging to get patients to brick-and-mortar facilities. This was especially true in cardiac rehab.

"Before COVID-19, Geisinger already had been thinking for a long time about improving participation in cardiac rehab, a Class I recommendation for eligible patients," said Alex Zimmerman, DNP, RN, vice president of the Heart & Vascular Institute at Geisinger. "At any given time, our six brick-and-mortar cardiac rehab centers had 85-90 active patients.

"We knew rehab was underutilized in our system, and we were involved with initiatives to improve participation," he continued. "National statistics show only about 25% of eligible patients start a program, and fewer than 10% complete."

When COVID-19 hit, Geisinger closed and reopened its cardiac rehab facilities three times, which was disruptive for patients and staff. With a patient population that couldn’t miss work to attend rehab, and rural geography adding challenges, the health system had the perfect storm for even less engagement.

To make better health easier, Geisinger started looking for a solution to how it could increase participation in cardiac rehab programs.

"Heart disease is the leading cause of death in the U.S. Allowing patients to continue their recovery at home can slow this rising cause of death."

Alex Zimmerman, DNP, RN, Heart & Vascular Institute at Geisinger

PROPOSAL

The core tenets of cardiac rehab involve a personalized program, supervised by a care team, that supports education, exercise, nutrition, medication management and counseling for patients recovering from heart conditions.

Health IT vendor Recora proposed to Geisinger a technology and services platform to enable virtual cardiac rehab delivery. The Recora program had three elements, Zimmerman explained:

• A multidisciplinary care team of exercise physiologists, dietitians and others who would work under the supervision of Geisinger physicians to deliver care.
• A personalized recovery kit mailed to a patient’s home. The kit is tailored to each patient and includes stretching bands, monitoring equipment, resistance bands and an internet-enabled tablet, if patients need a device.
• An individualized treatment plan that is crafted after a comprehensive evaluation of a patient’s unique needs and goals for their recovery. Patients could participate in cardiac rehab that is fully compliant with CMS standards.

"This platform would allow us to address the transportation and wait-time challenges that once had been major barriers to patient engagement in this therapy," Zimmerman noted. "And we would be able to move forward with both in-person and virtual offerings for our patients.

"We could preserve our brick-and-mortar centers for patients who preferred in-person care or were higher risk," he added. "And we could use virtual options to reach patients who might not be able to reach our facilities."

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MEETING THE CHALLENGE

As a health system, Geisinger is incentivized to provide the right care that will hopefully change its patients’ health trajectories, reduce resource utilization and decrease costly procedures for patients. From a clinical operations perspective, offering virtual cardiac rehab aligned well with the care models delivered at the Geisinger Heart & Vascular Institute.

"Prior to implementation, Recora and Geisinger worked closely to collaborate on a partnership," Zimmerman said. "It was critical to bring along our regulatory, legal, contracting, revenue, IT and clinical leadership to take this initiative forward. The vendor worked closely with our IT and operations teams to ensure we built the appropriate workflows for clinical documentation and billing.

"Recora improved operations by engaging patients eligible for cardiac rehab who might not otherwise participate," he continued. "Essentially, the vendor helped to educate patients in our communities about cardiac rehab. We launched care in June 2021, with the vendor’s clinical staff and technology enabling us to provide cardiac rehab virtually."

Over time, Geisinger has integrated the vendor's workflows with its clinical and financial workflows in the health system's electronic health record.

"This has helped our health system with better resource management and patient loyalty," Zimmerman explained. "We've had patients say, 'Because I got my cardiac rehab from home, I could now have the strength to show up to my doctor’s office at Geisinger.'"

RESULTS

Since the launch of the program in June 2021, Geisinger has delivered more than 30,000 virtual cardiac rehab appointments with Recora. The health system has grown cardiac rehab participation by three to four times, despite temporary closures of the rehab facilities due to COVID-19.

Because of better patient outreach and education through the vendor, Geisinger has had more patients interested in cardiac rehab from the get-go. This helped the facility volumes, as well.

"This leads me to the next metric: We have seen consistently high patient satisfaction scores with the program, including a Net Promoter Score of 80-plus," Zimmerman reported. "Virtual programs offer convenience and quality outcomes.

"For example, in January of this year, a patient with heart failure began to feel weak and slightly congested during a virtual cardiac rehab appointment," he continued. "The care team facilitated patient follow-up with their cardiologist soon after. Because of timely follow-up, the patient shared they were feeling and breathing much better."

Geisinger has had many such patient stories in the last two years, and it has a better sense of a patient’s home and social determinants of health. In the last two years, patients in the virtual cardiac rehab program have been connected to housing resources, identified earlier for cardiac procedures, and appropriately connected to their care teams at Geisinger.

"We also celebrate with them," Zimmerman noted. "Upon completing their virtual programs, patients who are compelled on their own sometimes send in photos of celebrations with their loved ones.

"Clinically, this program also has had an impact on outcomes for our patients," he continued. "We have seen blood pressure improvements due to better diet and exercise. More than 80% of those with hypertension have seen significant improvements in their blood pressure. It’s stories like the aforementioned one that drive better follow-up and reduce hospitalization rates."

ADVICE FOR OTHERS

Annually, at least three million Americans will experience a heart attack, heart failure or undergo a cardiac procedure, according to the CDC. Of those eligible for cardiac rehab, only 8% complete the program, largely due to access barriers.

"Nationally, patients often wait 40 days to get into a program and, when they do, many drive several hours a week to attend therapy," Zimmerman said. "Studies show that rural populations, women and minorities all are less likely to participate in cardiac rehab due to access challenges. Expanding access to cardiac rehab via virtual models is critical for addressing the heart disease crisis in the U.S.

"At the height of the pandemic, many health systems like ours quickly adopted virtual options to get patients back into care," he continued. "Recent studies have found virtual cardiac rehab delivers similar outcomes to facility-based care and may be easier to complete."

In one study, almost 50% of virtual participants were from marginalized communities historically less likely to participate in cardiac rehab, he added. And in a 2022 Kaiser California study, patients who participated in a virtual cardiac rehab program experienced 21% fewer hospital stays over 12 months than those who attended a facility program.

"Better access to recovery at home keeps patients more engaged in their health but less likely to be hospitalized," Zimmerman said. "Given how underutilized cardiac rehab has been historically, virtual care provides a long-term option to make better health easy.

"But the reimbursement for virtual cardiac rehab is uncertain, as these programs largely gained traction with waivers allowed during the public health emergency," he continued. "And while Congress extended telehealth rules through 2024, virtual cardiac rehab was not included in this legislation."

The U.S. healthcare system cannot afford to lose the progress it has made in the last three years, he added.

"An individual with heart disease costs Medicare twice as much as the typical beneficiary," he concluded. "Heart disease is the leading cause of death in the U.S., and cases are only rising. By 2030, we can expect it to affect 40% of the population. Allowing patients to continue their recovery at home can slow this rising cause of death."