The early referral gets the rehab

Henry Ford Hospital in Detroit boosted rehab rates to over 70%.

Where: Henry Ford Hospital, an 802-bed tertiary care hospital in Detroit.

The issue: Increasing patient attendance at cardiac rehabilitation.


Before 2011, the process of referring Henry Ford's cardiac patients to rehabilitation was simple. “An order had been given and faxed to the rehab facility. Then the patient had been given a phone number and told to call,” said Quinn Pack, MD, previously a cardiology fellow at Henry Ford and now a preventive cardiology fellow at the Mayo Clinic in Rochester, Minn. “A passive referral—we're just saying, ‘Hey, you ought to check this out.’”

There was only one problem with that system. “Most patients did not call….Only the very most motivated patients were coming in at four, five or six weeks,” said Dr. Pack. When patients did call for a rehab appointment, they often had to wait weeks before beginning so that insurance preauthorizations could be completed.

Dr. Pack and colleagues decided to see what would happen if they nudged the rehab entry process along a little.

How it works

Starting in February 2011, a group of patients was more actively referred to rehab. “We talked to the patients, we encouraged them to go.…We emphasized that the orientation was a free session that everyone ought to come to,” said Dr. Pack. The patients also all left the hospital with an appointment for rehab orientation arranged by the physician researchers.

However, while half of them received an orientation appointment with the standard delay—about five weeks after hospital discharge—the other half were randomized to an early rehab appointment, in 10 days or less. About a third of the patients still required preauthorization before officially beginning a rehabilitation program, but under the new system, they could attend orientation while that was in process.


Attend they did, according to results published in the Jan. 22, 2013, Circulation. “We were able to get 70-plus percent of the people in the early group actually into cardiac rehab orientation,” said Dr. Pack. In comparison, only 59% of the patients in the standard referral group showed up at orientation.

The scheduling of an early appointment appeared to close the gap between patients' expressed interest in cardiac rehabilitation and their actual attendance. “Studies suggest somewhere between 70% and 80% of patients are willing to consider going,” said Dr. Pack. “The national rates [of attendance] are much closer to 30% to 35%.”

The study also found a trend toward patients exercising more and being more likely to complete rehab, although those differences weren't statistically significant.


The secondary outcomes were hard to change, because early referral is only the first step to getting patients to complete rehabilitation, according to Dr. Pack. “People make their decisions after coming to three or four cardiac rehab sessions whether this is something that's for them.…The cardiac rehabilitation programs are going to need to work with patients once they show up at orientation, to get them all the way to the very end of the program,” he said.

Busy rehab programs also had to work on opening up their schedules to early appointments. “We had to push them, ‘You just have to find room for these patients.’ We got a little pushback that way from the programs,” said Dr. Pack.

Preauthorization requirements also continued to be an obstacle in the process.”We would have people who would show up to orientation and we would have to say, ‘We're going to need you to wait about another week before we actually have you start exercising,’” said Dr. Pack.

But unlike insurance regulation, early appointments are fully under the control of hospital clinicians, which is both good and bad.

“The trick is making sure that all of the cardiologists and all of the hospitalists, residents and fellows know to make sure that that's part of the discharge package,” Dr. Pack said.

Next steps

At Henry Ford, this administrative process is currently underway to expand early referral from trial patients to everyone who would be eligible. Meanwhile, Dr. Pack is interested in shrinking the referral time even further.

“In the future, I'll probably be looking at transitioning people, if we could do it, in more like the three- or four-day range. That would be my ideal goal,” he said.