Abstract
Background
Although comprehensive cardiac rehabilitation (CR) is an effective treatment for cardiovascular diseases, its implementation in Japan remains insufficient. Following the 2022 Basic Act on Cardiovascular Disease Prevention, each prefecture has established specific targets.
Methods and Results
We report our experience implementing and managing CR programs across hospitals of different sizes in Yamaguchi Prefecture, Japan, including Tokuyama Medical Association Hospital (initiated in 2019), Mitajiri Hospital (initiated in 2022), and Yamaguchi Prefectural Grand Medical Center. Hospital size and functionality correlated with the diversity and number of healthcare professionals available to provide CR services. In mixed-care hospitals, both inpatient and outpatient CR participants were older compared with acute-care hospitals. Insurance reimbursement calculations and bed-type restrictions affected CR service delivery. The CR team exemplifies interprofessional collaboration in cardiovascular care.
Conclusions
Even without all the necessary professional roles, patients can benefit significantly from CR implemented using available resources. Building effective organizations requires embracing diversity and enabling each profession to demonstrate its expertise while ensuring the psychological safety of team members.
Key Words: Cardiac rehabilitation, Community hospitals, Diversity, Psychological safety, Team-based healthcare
Comprehensive cardiac rehabilitation (CR) is effective therapy for ischemic heart disease and heart failure,1–3 but despite being an evidence-based treatment with proven ability to improve patient outcomes, it has not been sufficiently implemented throughout Japan.4,5 In 2022, the Japanese government enacted the Basic Act on Cardiovascular Disease Prevention, which established specific targets for each prefecture.6 However, CR services for the recovery and maintenance phases of patient care were insufficiently implemented in Yamaguchi Prefecture; thus, their implementation was urgently needed. The lead author established and implemented CR programs at 2 mixed-care hospitals and subsequently managed a CR program at an acute-care hospital in Yamaguchi Prefecture. Here we describe our experience in implementing and managing CR services across regional hospitals in the context of staffing and facility limitations.
CR Startup and Management
In 2019, the CR program was initiated at Tokuyama Medical Association Hospital. First, a clinical team conducted site visits to observe the operation of CR facilities in and beyond the study prefecture. After completing the equipment selection process and obtaining facility certification, we launched comprehensive CR services for both inpatients and outpatients at 6 months after the start of preparations. An interdisciplinary CR team was established that included cardiologists, physical therapists with extensive experience in orthopedic and cerebrovascular rehabilitation, cardiovascular ward and rehabilitation department nurses, clinical ward pharmacists, and registered dietitians. The team conducted regular interdisciplinary conferences in which they discussed individual patients’ rehabilitation progress, established their treatment goals, and planned patient education strategies, with each profession actively contributing to the CR program (Figure 1).
Figure 1.
Multidisciplinary team conference on cardiac rehabilitation at Tokuyama Medical Association Hospital. Participants included cardiologists, physical therapists, nurses, pharmacists, registered dietitians, and medical laboratory scientists.
Mitajiri Hospital, a regional private healthcare facility, implemented its CR program in June 2022. Implementation proceeded smoothly from its inception owing to the presence of certified CR instructor among the physical therapy staff and nurses with acute-care CR experience. Although it is a mixed-care hospital, its chronic care beds are limited to community-based integrated care beds, making it difficult to calculate CR costs. Therefore, we implemented a CR program that primarily focused on providing outpatient services. To promote awareness and knowledge about CR, we organized lectures for local healthcare professionals and the general public.
Following the implementation of CR in 2015, the Yamaguchi Prefectural Grand Medical Center has consistently provided CR services to nearly all inpatients with cardiovascular diseases. A large, acute-care hospital, the facility has maintained a comprehensive multidisciplinary team of healthcare professionals dedicated to CR (Figure 2).
Figure 2.
Multidisciplinary team conference on cardiac rehabilitation at Yamaguchi Prefectural Grand Medical Center. Participants included cardiologists, rehabilitation physicians, physical therapists, cardiac ward nurses, pharmacists, registered dietitians, and medical social workers.
Staffing Levels and Patient Profiles Across Hospital Categories
The Table shows the differences in staffing and patient backgrounds according to hospital scale. The bed capacity and hospital functionality scales appeared to positively correlate with the diversity and number of healthcare professionals available to provide CR services. At Mitajiri Hospital, although only specific professions were involved, a heart failure care instructor–certified nurse used a heart failure notebook to monitor deterioration in patients’ symptoms, as well as their self-monitoring ability, medication adherence, and dietary conditions during each CR session. Through consultation and guidance, the nurse covered the roles typically performed by multiple professionals (Figure 3).
Table.
Differences in Staffing and Patient Backgrounds According to Hospital Scale
| Yamaguchi Prefectural Grand Medical Center |
Tokuyama Medical Association Hospital |
Mitajiri Hospital | ||||
|---|---|---|---|---|---|---|
| Type of hospital | Acute care hospital | Mixed care hospital | Mixed care hospital | |||
| No. of beds | 504 | 330 | 128 | |||
| Observation period | 1 year from April 2023 | 2 years from October 2019 | 1 year from June 2022 | |||
| Staff on cardiac rehabilitation team | ||||||
| Physician | 6 cardiologists, 2 rehabilitation physicians |
2 cardiologists | 2 cardiologists | |||
| PT | 4 | 4 | 2 | |||
| OT | 2 | 0 | 0 | |||
| Nurse | 26 | 2 | 2 | |||
| Pharmacist | 3 | 1 | 0 | |||
| Registered dietitian | 1 | 1 | 0 | |||
| Medical social worker | 1 | 0 | 0 | |||
| Clinical psychologist | 0 | 0 | 0 | |||
| Certified heart failure care instructor |
2 nurses, 1 pharmacist, 1 registered dietitian |
0 | 1 nurse | |||
| Cardiac rehabilitation instructor | 4 PT | 0 | 1 PT | |||
|
Inpatient (n=366) |
Outpatient (n=18) |
Inpatient (n=73) |
Outpatient (n=26) |
Inpatient (n=4) |
Outpatient (n=23) |
|
| Characteristics of cardiac rehabilitation patients | ||||||
| Age (years) | 76.8±13.2 | 71.9±8.2 | 84.5±7.1 | 76.8±13.5 | 81.5±3.9 | 79.4±6.4 |
| Male, n (%) | 229 (63) | 7 (39) | 34 (47) | 15 (58) | 3 (75) | 15 (65) |
| BMI (kg/m2) | 21.5±4.1 | 23.5±5.3 | 21.8±3.6 | 23.0±3.1 | 21.7±1.9 | 23.3±3.4 |
| SPPB | 7.3±4.2 | 10.8±1.6 | 3.9±3.7 | 9.4±3.4 | 8.0±2.5 | 10.6±2.0 |
| 3-month retention rate (%) | 100 | 69 | 87 | |||
BMI, body mass index; OT, occupational therapist; PT, physical therapist; SPPB, Short Physical Performance Battery score.
Figure 3.
Cardiac rehabilitation at Mitajiri Hospital. Patient education and management are conduction using a heart failure notebook by a heart failure care instructor–certified nurse.
In mixed-care hospitals, especially Tokuyama Medical Association Hospital, compared with acute-care hospitals, CR patients in inpatient and outpatient settings tended to be older with lower scores for the Short Physical Performance Battery, suggesting a higher prevalence of frailty. These inpatients with cardiovascular diseases require extended rehabilitation sessions in preparation for discharge to home or care facilities but face restrictions based on the type of hospital bed they occupy. In community-based integrated care units, it is difficult to calculate reimbursement for CR. Additionally, in recovery rehabilitation wards, insurance reimbursements for rehabilitation of cerebrovascular diseases are higher. Therefore, from a hospital management perspective, the admission of CR patients tends to be given lower priority.
Enhancing CR Staff Diversity
CR is a long-term multifaceted and comprehensive program in which a multidisciplinary team collaboratively implements exercise therapy based on an individual patient’s medical evaluation and exercise prescription, coronary risk factor modification, patient education and counseling, and optimal pharmacological treatment.3 In Japan’s medical hierarchy, physicians often occupy the top position, thereby inhibiting spontaneous opinions and actions from other healthcare professionals. To provide better CR services for patients, each professional must utilize their expertise, actively exchange opinions, and proactively approach their work.7,8 To create such a multidisciplinary team, it is essential to ensure psychological safety, which refers to an environment or atmosphere where individuals feel they can freely express opinions, ask questions, and acknowledge mistakes within their team or organization.9,10 This feature contributes to enhanced team performance, creativity, and learning promotion, ultimately improving overall organizational outcomes, but largely depends on the role of leadership, and the leaders of CR, who are often physicians, need to be particularly mindful of this point. The key is to avoid invasive communication. To build better teams, healthcare professionals must learn about effective leadership and organizational management techniques.
Because rehabilitation is conducted during day shifts, it attracts senior physicians and cardiologists, who prefer to work only day shifts for varied reasons. At Tokuyama Medical Association Hospital, although the continuity of CR services was at risk owing to the transfer of a full-time cardiologist, it was maintained through the recruitment of a senior cardiologist.
Conclusions
In an era in which team-based healthcare is at its peak, the CR team represents the ultimate example of interprofessional collaboration in the cardiovascular field. Every involved profession must demonstrate its expertise, and must establish a community-based system that provides better comprehensive CR for patients with cardiovascular disease. Even if it is not possible to assemble all professional roles required for a CR team, patients can still receive significant benefits from CR implemented using available resources. To build a vibrant organization in which professionals from all disciplines can actively engage in CR, it is essential to embrace professional diversity.
Disclosures
The authors report no conflicts of interest.
Funding
None.
IRB Information
This study received approval from the Ethics Committee of the Medical Corporation Koutokukai Mitajiri Hospital (approval no. 507), and conformed to the provisions of the Declaration of Helsinki.
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