Measure Description: Percentage of patients, age ≥18 y, evaluated in an outpatient setting who, within the previous 12 mo, have had a new HFrEF event or exacerbation and have not participated in an exercise training program, such as provided in CR programs, for the qualifying event/diagnosis, are to be referred for exercise training.
Numerator	Patients in an outpatient clinical practice who have had a new HFrEF event or exacerbation and have not participated in a supervised exercise training program (e.g., as a CR program) during the previous 12 mo, who have been referred to an outpatient CR program Referral is defined as:  1. Documented communication* between the healthcare provider and the patient to recommend an outpatient CR program   AND  2A. Official referral order† is sent to outpatient CR program   OR  2B. Documentation of patient refusal to justify why patient information was not sent to the CR program‡ Note: Performance is met if steps 1 AND either 2A (official referral order transmitted) OR 2B (patient refusal documented in the patient’s medical record) are completed and documented. *All communications must maintain appropriate confidentiality as outlined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). †All patient information required for enrollment should be transmitted to the CR program. Necessary patient information may be found in the hospital discharge summary. ‡Patients who refuse a CR referral should not have their data transmitted to the receiving CR program against their will.
Denominator	All patients in an outpatient clinical practice who have had HFrEF during the previous 12 mo
Denominator Exclusions	Patients age <18 y Patients who leave clinic visit against medical advice Patients have already participated in or had already completed a CR program prior to clinic visit
Denominator Exceptions	Documentation of a patient-oriented reason that precludes referral to CR (e.g., no traditional CR program available to the patient, within 60 min [travel time] from the patient’s home, or patient does not have access to an alternative model of CR delivery that meets all criteria for a CR program) Documentation of a medical reason that precludes referral to CR (e.g., patient deemed by a medical provider to have a medically unstable, life-threatening condition, or has other cognitive or physical impairments that preclude CR participation) Documentation of a healthcare system reason that precludes referral to CR (e.g., patient resides in a nursing care or long-term care facility, or patient lacks medical coverage for CR)
Measurement Period	Encounter
Sources of Data	Medical record or other database (e.g., administrative, clinical, registry)
Attribution	Measure reportable at provider and facility level
Care Setting	Outpatient
Rationale
CR services have been shown to help improve functional status and may help reduce morbidity and mortality in persons with stable chronic heart failure with reduced HFrEF. However, these services are used in a minority of eligible patients (122,123). A key component to outpatient CR program utilization is the appropriate and timely referral of patients. Generally, the most important time for this referral to take place is while the patient is hospitalized for a HFrEF. This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize the appropriate referral of a patient to an outpatient CR program. This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve patients with HFrEF. This performance measure is provided in a format that allows for easy and flexible inclusion into such performance measurement sets. Effective referral of appropriate inpatients to an outpatient CR program is the responsibility of the healthcare team within a healthcare system that is primarily responsible for providing cardiovascular care to the patient with HFrEF during hospitalization. Published evidence suggests that automatic referral systems accompanied by strong and supportive advice and guidance from a healthcare professional can significantly help improve CR referral and enrollment.
Clinical Recommendation(s)
2013 ACCF/AHA heart failure clinical practice guideline (7) 1. Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status (124–130). (Class 1, Level of Evidence: A) 2011 AHA prevention of cardiovascular disease in women guideline update (131) 1. A comprehensive CVD risk-reduction regimen such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program should be recommended to women with a recent acute coronary syndrome or coronary revascularization, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease (Class 1; Level of Evidence A) or current/prior symptoms of heart failure and an LVEF ≤35%. (Class 1; Level of Evidence B)

ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; CR, cardiac rehabilitation; CVD, cardiovascular disease; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; and PM, performance measure.