Okay, I think we can go ahead and get started. Welcome everyone. Thank you for coming to our session. Just the usual reminders to silence your cell phones and please complete the evaluation forms at the end and a reminder to visit the PMR pavilion for the educational opportunities there. I am David Prince. I'm the Medical Director of Cardiopulmonary Rehab at Montefiore Medical Center in New York City and today we're going to be talking about a number of different aspects of advanced medical rehabilitation. We have Dr. Bartels is going to be talking about pulmonary rehabilitation and Sophia Prillick about advanced cardiac and transplant and advanced cardiac patients and then Dr. Whitson is going to bring it all together with an overview of the whole continuum of advanced rehabilitation. So I'm going to kind of set the stage and although all of us do cardiopulmonary rehabilitation, I want to share some ideas for the general physiatrists who are here and try to give you something that you can take away from even if this isn't your primary specialty or your primary interest and then we'll hear about advanced lung disease, advanced heart disease and Dr. Whitson will wrap it up. So I have no disclosures. So the idea behind the session was to empower the audience to be able to approach medical and surgical teams as physiatrists who can improve the outcomes for all of their patients and of course we want to reinforce, this is a theme you heard it this morning, the importance and the value of physiatrists in all medical settings. There's really no setting in which we cannot contribute. It doesn't matter how advanced the patients are, whether they're advanced cancer patients or critically ill patients in the ICU, we bring a lot of value everywhere we consult. And just to generate some ideas and think about where you can start bringing additional value and both to a practice and to patients. So I'll talk a little bit more in a few minutes about data collection, what to collect, just high level overview. If there are benchmarks then someone's paying attention to them. Of course anything related to joint commission or regulatory bodies or regulatory surveys is always of great interest in all of your institutions. And there may be some that are of particular interest to your institution either because it's areas that they have struggled with or areas that they've excelled with and they really want to take it to the next level. So that's for you to explore and find in your own institutions. I have two reminders to be sure that you're collecting data securely. The burden is on whoever's collecting it and I urge everyone to investigate with their IT teams how to do that. So just a high level reminder and overview when we're talking about quality there are domains of quality and these are all buzzwords that everyone's heard safety effectiveness patient centered care timely efficient and equitable. And if you really we all know what those mean but if you really keep that quality lens as you practice and go through your practice then you'll start to see that there are opportunities to improve these aspects of the care that's being provided because there's no such thing as a perfect system. The big questions to kind of start with are how can I improve the care either for my patients the individuals I'm taking care of or of the population as a whole. And also how can you lower the cost of care which doesn't necessarily mean lowering the cost that you're providing you might have an idea of where something can be made more efficient or where you can help with throughput on another team. So it's I encourage you to think about how you can contribute to other services. That's really kind of the idea and the theme of what I wanted to share with you guys. So just a couple examples of value based care conceptually there's you know care coordination that takes place in acute rehab GG codes or functional outcomes that are collected and reported to Medicare telemedicine remote monitoring has can have value based outcomes and there can be care plans that the focus is on improving the value and improving the outcomes whether that's reduced. These are just some examples reducing visits reducing narcotic use hospital readmission is a big one because of the cost associated with it and the reward for meeting quality outcomes and the penalties if hospitals do not meet them especially in the readmission metrics. So some value based care models that are listed here are the original five that CMS is value based programs I'm not going to go into them just showing them. And if you take those and kind of blow them out these are some of the the metrics that are being followed and the diagnoses that are being looked at and this is really pretty much just a reference slide so that if that if afterwards you want to get ideas it's all kind of on one page where you could think about if there's any of these either diagnoses or complications that you feel you might be able to intervene and you would find welcome ears and active partners wherever you're practicing because these are important to every institution. And then in terms of the patient safety and adverse effects events composite in terms of that I was wondering OK so what are some I looked at it and what jumped out to me I'll show you on the next slide is areas where any physiatrist can make a difference in the hospital and you can see that this is a composite for the patient safety indicators and the pressure ulcers and falls and post operative complications of PE or DVT. These are all areas that physiatry it just it's made for physiatric intervention. So I would encourage you to think about if there's ways that you could contribute to the teams and reduce these complications certainly they're being looked at they're being followed they're being reported and you'll find active and supportive partners for all of those. In terms of readmissions you're going to hear a lot of these diagnoses that we're going to cover in these talks and just an idea here I do cardiac rehab. I have never been particularly interested in exploring in depth the musculoskeletal complications of cardiac patients but if you are a general physiatrist or an MSK person you could undoubtedly add a lot to any of these diagnoses or any of these teams and your expertise would be welcomed and valued because certainly all of these patients can have disease specific or procedure specific MSK complications that people are probably not really looking at or thinking about. In terms of data collection I encourage you to look at the hospital mission statement and strategic plan for your institution. People put a lot of effort into crafting those and they really do guide the direction of the institution and highlight the interests of where they want to go. So if you and you really get a flavor for what is important to the people in leadership in your institution there. In terms of what data do you have access to that's a good place to start. Look at what you actually are already collecting. It's exciting to think about a new thing that we're going to start collecting and looking at but if you're collecting it electronically or through an EHR it might take quite a bit of work with your IT department until you're actually capturing that. So start with what you actually have access to and think about what you can improve. And I have the little thing no money no mission meaning the mission is important but clearly the things that will improve the bottom line and reduce waste or potentially make money are going to be valued. So if you have a choice between things that are going to be of interest financially or have financial impact or not then that's just something to take into account and weigh. So in wrapping up you're going to hear in the next talks about from experts who have very very data rich areas that they're working in. Think about what is of interest to you when you go home. Think about what's of interest to your institution even outside of your department. Figure out the overlap and think about what data you have access to immediately like I said or that you could maybe get working with someone in your department or an adjacent department or a colleague who you already have a relationship with and then the reach goal for what you want to get out of your EHR down the road. That might be a long process. Reach out to your leadership. They can help guide you with resources and important perspective and always check once again with your IT department and make sure that where you're storing the data is actually a secure location and confirm that with them. Don't make any assumptions about that. Start collecting, set up a plan, review it regularly and then once you're confident that you are collecting your data and you're happy with the way it's going then you can use that to drive your PDSA cycles and your quality improvement and the last reminder is to document for yourself your journey towards collecting that data in a standardized regular way because that will be useful in your retelling of your successes in how you actually got to that point and people tend to forget all the steps that they went through to get these things set up. Just a reminder that we're all superheroes. We have lots of skills. We do lots of things and we're at the middle of that. We understand and communicate and lead with everyone, everyone who we interact with and that's it for me and next up is Dr. Bartels. All righty. So everyone, talking about cost benefits and things, this is not what I'm going to be talking about with advanced lung disease care. It's probably not your most cost effective treatment. However, you do have a very important role as a physiatrist because these are very profitable patients for your system, but they're also very expensive if things don't go right. And you can actually have a very big part of playing a role in making sure that things go in the right direction. No major disclosures. So what is it? Well, what are we thinking about? Lung transplant has become more common. There have been more transplants needed than there are available organs. Transplant requirements or needs have gone up. COVID was partially to blame for that because there were a fair number of, in the early parts of the pandemic, patients who required transplants. But we still have patients who have lung disease due to either smoking and other causes, or they may actually have lung disease that's coming from age, rheumatologic disorders, and other things. So this is something that's going to be with us for a long time. Outcomes are really dependent on patient selection and preparation, and we have a role for that because we can help prepare the patients. But they also, there's a lot of motivation, and we can help patients who are very depressed and very deconditioned get into that point where they can get this. And then once they've gotten the transplant, we are very important in that early mobilization, and then also making sure you maximize the outcome after the transplant. So what kinds of things do we see? Usually it's COPD. We see a lot of patients with restrictive lung disease, and that's actually where the COVID patients generally fall into. And then we have roles all throughout, pre, peri, and post-operatively. So, but when do you get these patients referred? Well, any patient that you have who's got any degree of lung disease is probably eligible for pulmonary rehab. But in COPD, pretty much any of the patients are eligible at any time. So if you have a patient who's going in the direction of advanced lung care, those patients are all eligible. The same thing goes for patients who have interstitial disease. Anybody who's going forward to get advanced lung care is probably an eligible patient. Now you start the rehabilitation as early as you can in that journey because you really are improving function, and you want to delay the transplant, or if you can, maybe they actually can survive well enough without needing the transplant. Because transplant is no cure. Transplant patients with lungs have the lowest survival and roughly about a five-year, 50% survival. That's not a really great odds, but most patients who get transplanted have about a 90% one-year mortality rate. So it's a really good exchange, but you're not talking about a disease that is going to miraculously go away, and these patients are gonna have long, long-term survivals. Kidney, liver, and heart have better survivals. So what do we do? Well, we improve their quality of life. We decrease their respiratory symptoms. We reduce psychosocial symptoms. We can increase their exercise tolerance and improve their ability to perform ADLs, and this is very important. A lot of these patients have a hard time even taking a shower or getting dressed, so you can get them to the point where they're household independent. That's really important. Community independence gets to be more problematic because as one of my patients said to me, oxygen giveth, but it taketh away, because you get the oxygen, but then you have to carry the equipment, and you don't have a lot of endurance. So if you're carrying the old steel tanks, that really did you in, but now even with the portable oxygen systems, those systems weigh anywhere from five to 10 pounds, and that's a big burden for somebody with lung disease to carry. Increased survival is not absolutely clearly proven. Unlike cardiac rehabilitation, this does not have as much of a survival benefit, but a very big morbidity benefit. Some of the data I'll talk to about advanced pulmonary disease in the emphysema population comes from our old National Emphysema Treatment Trial. Yeah, it's old, but there hasn't been a really large study since then, so we rely on this, and this was a study with several thousand patients. What did we find? Well, we increased their exercise endurance and tolerance on a CPAT and six-minute walk distance. The UCSD, University of California, San Diego, dyspnea scale showed a marked improvement. The Borg scale of exertion at a given level, or scale of perceived exertion at a given level of exertion improved, so it was lower. They all had an improvement in their quality of well-being score, their SF-36 medical and physical health surveys. But we don't have as much data for our other patients, so if we have our interstitial lung disease patients, nobody's done as large a study. There are some smaller studies on patients with pulmonary hypertension and smaller groups of interstitial lung disease that show similar findings, but I can't really give you that as massive evidence because we're not talking cases where you have several thousand subjects. One of the big things that you wanna do pre-transplant is get patients to walk as far as they can. If they can do better than 600 feet on a six-minute walk test, their morbidity at the time of operation is markedly decreased. Now, that's gonna be really hard to do with a lot of these patients, but if you can get them to that level, that's good. If you get them above 200 feet, you're okay. If they can't walk more than 50 feet, you may have a bed-bound patient after transplant, and that's gonna be a really big challenge because every patient is gonna be worse off after transplant immediately than they were before. So if you can walk 600 feet, you'll walk 200 after transplant. Getting you home is easy. If you're walking 200, you're walking 50 after transplant. We can fix that. If you're walking 50, you're not getting out of the bed very easily. So that's something you have to think about as part of what you are assessing as you're looking to work with them. Pulmonary rehabilitation for most programs has anecdotally, we have not been able to tease the data out because there's so many things that have been changed in transplant, do improve outcomes, and most transplant surgeons and transplant pulmonologists will not run a program unless they have an attached pulmonary rehab program. Big thing, smoking cessation. You have to stop smoking if you're a patient with this advanced lung disease. One of my favorite pulmonologists said, treating a smoker is like bailing water on the Titanic. It ain't gonna work. So these patients have to stop smoking and it's part of the requirements for transplant. Oxygen therapy is critical and you give the patients a lot of it and I'll talk a little bit more about it, although I could go on for half an hour. We don't have the time for that, but it's basically give them what they need for the exercise that they need to do because it'll allow you to actually keep the rest of their body in great shape. Surgical preparation and education, talking to them about nutrition because a lot of these patients come in and they're actually very emaciated. They have a lot of sarcopenia because if you're breathing really hard, exhaling and inhaling are both active processes in these patients. They actually at rest will be using two meths of energy. But if you eat a lot when you have lung disease, think about how you feel after you ate way too much after Thanksgiving dinner. Your diaphragm is pressed upon. You can't take a deep breath. They feel that with very small meals. So frequent small meals, a lot of work with nutrition in order to maintain lean body mass is critical with these patients. And pulmonary toilet, meaning clearing secretions and making sure that they're not having problems with recurrent infections, bronchitic problems, and so forth. So oxygen therapy, it helps them to survive longer. I think everybody here is familiar with the long-term oxygen treatment trial and the nocturnal oxygen treatment trial, which were done 30 years ago, but then were redone within the last 10 years and showed that those benefits were actually real. Those oxygen benefits cannot be underestimated. It's really important to have good oxygenation. You also want to preserve the other organs. You want the brain, the liver, the kidney, the heart to actually also be in good shape when you do the transplant. You could do it nasally, but if you have to go to higher flow, face mask is fine. There are high flow nasal systems that can go up to 20 or 30 liters. Transtracheal catheters are possible, but that's usually in a terminal patient. We don't do that much in a transplant because then you have a dirty site that's actually gonna be involved with the transplant. But you use whatever's needed with exercise. If it's a COPD or some other retaining patient, you turn it back down when they go to rest. But don't worry about them retaining with exercise because the exercise is a driver to breathe and they won't retain during that period of time. But don't forget to turn it back down when you get them back down to rest, to recovery. So let's talk a little bit about ECMO. ECMO has changed the game. We don't have to intubate patients if they come in with an exacerbation. It means that they can be mobilized. It means that they actually can continue to eat. Nutrition is better. They don't get sedated. They don't have all of the side effects that come with the delirium and things. But you need to have your team round in the ICU and work with the team there. You may need to do the quote unquote we call bag and drag, which is meaning if you need to, you ventilate and have everything going with the patient. It may take you half an hour to 45 minutes to prep the patient, do five minutes of exercise, and then half an hour to 45 minutes to put them back into the room because there's all this equipment that's hooked up. But getting them up and doing that walking is infinitely useful because it keeps them as a viable candidate for getting their advanced treatments. We looked at our own data over 12 months, lower length of stay, no complications, great cost savings, and one of the biggest ones was in actually the sedating medications. If you're not paralyzing and sedating patients, you're not putting them on very expensive medications like Versed and so forth. And that, just the pharmacy cost savings over the 12 months was over a million dollars. So there's a lot of cost savings that can be incorporated in that. But you do need to make sure that you have dedicated resources that you're not then taking those therapists and those respiratory therapists and other people from the non-ICU type settings because then you're going to actually incur more costs there because you're not mobilizing the patients there. So you have to get the dedicated resources. So what is ECMO? Well, there's a lot of different ways. There's veno-arterial, veno-venous, arterio-venous, but the dual lumen, veno-venous, going through the neck is the best way to go because then you can mobilize the patient. It does require that you stabilize the catheter, but obviously if you're having femoral catheters, it's a lot harder to mobilize patients. The other thing is in adults, a lot of times there's vascular complications with ischemic limbs. So it's much better if they actually do the EJ route and you actually have the veno-venous system. The device basically looks like this. It's the components of a cardiopulmonary bypass pump. You've got a pump, you have an oxygen membrane, oxygenator, an inflow and an outflow track. It's pretty darn simple. It's some plumbing with basically a membrane. This is what the whole thing looks like on a cart. So although simple, there's a lot of monitors and other things that are attached to it. This is what it looks like on a patient. You can tell which is the venous blood and which is the arterial blood, right? One is blue and one is red. It really does work. And here's an example of a patient that we had who was waiting for transplant, collapsed in the hospital while getting an ABG pre-transplant evaluation and was not intubated. She was in the ICU for 60 days, all of those days on ECMO until she got her transplant. You can see nicely over her head here, the venous and the nicely oxygenated arterial blood. She then had her transplant successfully. Whoops, I don't know why it went backwards. Had her transplant and then the picture with her dressed out nicely is at the Christmas party that year, and then she went back to running again. So you can have a very successful outcome by doing this. This really does work. Now, it's essentially early mobilization in an ICU setting. So what you're basically doing is you're getting the patient up, mobilizing them with the team and keeping them alive. The biggest problem we had with this poor young woman who was stuck in the ICU for 45 days was her iPad became her lifesaver because she was awake and alert and in an ICU. You can imagine being in that setting, you need to be able to contact the rest of the world. So that's another adjunct. That's not a medical device, but make sure they have good wireless and they can actually contact the rest of the world or they will go insane. We actually are not yet sending patients home with ECMO, but I foresee that in the near future that that may actually occur. Because if you are actually stable with this kind of a device, there's no reason that you don't have to be in an intensive care setting. Remember LVADs when they first came out, they were ICU and then hospital only within about five to 10 years, we were able to actually miniaturize the devices and have patients go home. This is just a quick thing that showed that most patients in this old study survived to transplant or survived to discharge if they were just abridged to recovery. And many of the patients went directly to home, a couple went to acute rehab, but very few ended up needing nursing home care. That's because if you mobilize the patients and you keep them active, you can avoid that level of deconditioning. So transplant, now you get the transplant, exercise capacity, what's happening? Well, transplant outcomes are better. I said 50% five-year survival. It's actually now it's around 55 to maybe 60%. It's improving, we're getting better, but it's not great. We took a look at a large number of our transplant patients to see what we actually found. We looked at 153 patients that we had complete pre and post transplant data within a year of transplant pre and within a year of transplant post. We did all types of lung disease, anybody with a double or a single lung transplant, and we took a look at what our outcomes were. What happened with their pulmonary function tests? Well, their PFTs, if you take a look at this, went back to pretty close to normal. You could see that their values were within the 85% plus range, which is essentially close to normal, where they were markedly abnormal before. And the shortness of breath that they reported, very few of the patients had shortness of breath. Yay, transplant works. However, when you look at their exercise capacity, it didn't change very much. First off, they were very similar, and then we take a look at where they went. Well, yes, everybody went up, but the number of the day was 50%. If you had a very severe COPD patient who had about 15% predicted exercise capacity, they were about 50% after transplant at one year. If you had somebody who was a relatively healthy pulmonary fibrosis patient who was rapidly progressing and had about 35% or 40% predicted, they had about 50%. So it wasn't like everybody doubled their capacity. It seemed there was a ceiling, and that ceiling is a pretty hard ceiling depending on whatever your diagnosis is. For COPD patients, for IPF and ILD patients, for cystic fibrosis patients, and these are young people. You would have anticipated they could do a lot better, and they themselves also kind of seemed to start capping out although the highest quartile patients did a little bit better, but they already started about 50%. They did not increase as much. Biggest changes for the worst impaired patients. There seems to be a cap. There's a ceiling there. So what in the world was going on? We also looked at patients who were at or above 50% for their exercise capacity. They didn't change. Patients who were below 50%, they changed. So 50%, what's with that? Well, the PFTs improve. Exercise is only about 1 1⁄2 times improved overall, but if you're really high functioning, it doesn't improve much. I had a lot of patients who would tell me before transplant I couldn't go up the stairs because I was short of breath. Now I can't do it because my legs give out. So did we really improve them? Yes, we did, but it seems that the exercise isn't working. Why is it? Why are we seeing these outcomes? Well, a big thing is the medications. It's not the high-dose steroids. You would like to invoke that, but remember, a lot of these COPD patients were on massive doses of steroids like four or five times a year when they got admitted. And lung transplant, usually within a couple of months, you're down to your five to 10 milligrams a day of maintenance prednisone. Yes, you start out on a gram of solumedrol, but it goes down. The big killer on these patients and what's different from them and all other transplant patients, so for example, kidney transplants have the least muscle impairment. Livers have some, but not as much. Hearts have more. Lungs are the worst. Lungs are the highest doses of calcineurin inhibitors because it's the most likely to reject, if you think about it. Every breath you breathe, you're inhaling. A non-sterile environment, whereas all the other organs are in a sterile environment, so you're always having immunostimulation, so they have to be on very high levels of these drugs. How does a calcineurin inhibitor work? Well, it's a little bit of magic. We're not exactly sure of all the mechanisms, but the big things that it does is it decreases cell differentiation. It decreases stem cell differentiation. It decreases cell hypertrophy, and those are all things that you want to do when you wanna knock down the humeral immune system. However, when you're trying to build muscle strength, there are muscle stem cells you would like to recruit. Yeah, they're not gonna work as well on calcineurin. You'd like to hypertrophy the muscle fibers. Yeah, not gonna work so well on calcineurin. You'd like to fiber type switch. Yeah, doesn't work so well on calcineurin. All this has been studied in animals. It hasn't been studied as well in human models, but the basic thing is if it's happening in animal models, these things are probably happening as well. So what can we do? Well, we can't stop the immunosuppression. We don't wanna add medications. People have tried things like adding growth hormone and so forth. It may help a little bit, but remember, these patients are on about 20 or 30 medications, so starting to add things like that may cause more complications. We can look at focus strengthening and conditioning pre and post. That's why what you do pre-transplant with these people is gold, because it gets them that stored, and then you can build up from it, although there's a sealing effect. And that's why also post-transplant, like that young woman who went back to running, she wasn't doing the time she did before her lung disease stopped her from being able to run. And our lung transplant surgeon went running with the group in the New York City Marathon. We're gonna support. He came back from that marathon and said, that was the hardest marathon I've ever done because it took them like almost six hours to finish. They can't run quickly because of this muscle limitation. So it is a very real fact, but they still improve, but it's at about half the rate. So if you normally have this kind of a strength improvement with exercise, it's like that. So I generally tell patients it's gonna take you twice as long to achieve your goals. So big thing to think about, what are your takeaways from this? Well, cardiopulmonary rehab is an important part of lung transplant, both pre, post, operatively, also for patients who may not get a transplant, but may have ECMO or be in the ICU with a lot of problems. The ECMO patients will get really good improvement in muscle strength because after their ECMO is discontinued, if it's a bridge, or it's not a destination, but just a bridge to recovery, they're not on these medications. But if a patient's on high doses of calcineurin inhibitors and the other medications for transplant, realize there can be muscle improvement, but it's slow. And if you look at our data, it's like 10% per year after that first year. So you're at like 60% the next year. You're like at 70% the next year. It does improve, but it's very slow. Learn about your local resources. Work, if your system is going to invest in transplant, they want good outcomes, they've got to invest in the therapy and the other support to make the patients thrive. And you're part of that because you're the one who's gonna be able to actually help really significantly decrease some of that preoperative morbidity, the perioperative morbidity, and then post-operatively, get these patients on their feet and help them have a better outcome. Provide your most cost-effective care. Don't throw care unnecessarily, but try to make it work within the system. Work with your insurance providers because a lot of these patients should, if they do need post-acute care, do not send them to a nursing home. Have an agreement with your care managers that you work with, these insurance companies, that they will let you send the patients to acute rehab. It wasn't a big problem for me because I had to establish the relationships. When they called, I knew I wasn't crying wolf. It was real, they needed to be there. And think to treat all of the transplant patients. Even if they're young and they look like they're in great shape, they are going to hit the ceiling and you need to work with them so that you can get the best outcomes you possibly can. All right, thank you guys. And now we move on to Dr. Whiteson. Hello, I'm Sofia Prilik. I'm a physiatrist at Rusk Rehabilitation, NYU in New York. So today I'm going to talk about advanced heart disease and the role of a physiatrist. OK. So specifically, I'm going to talk about advanced heart failure. So essentially, this is a disease state where conventional treatment and devices no longer work. So we have a patient that will present with severe persistent symptoms, shortness of breath, a decreased exercise tolerance. They will have severe cardiac dysfunction at times EF lower than 30% with right ventricular dysfunction as well. They may need high doses of IV diuresis. They will possibly be on IV inotropes and vasodilators and have low urinary output. They may have malignant arrhythmias. Their exercise capacity, as I mentioned, will be low with peak VO2 of less than 12 to 14 and decreased six-minute walk test of less than 300. They may also have extracardiac organ dysfunction, including cachexia, liver, kidney, and pulmonary disease, including pulmonary hypertension. So when we are called in to do a consult on a patient with advanced cardiac disease, what we see is someone with sequelae of prolonged bed rest, critical illness, including neuropathies, myopathies, encephalopathies, and multiple other comorbidities. So we have this vicious cycle of muscle-wasting sarcopenia as well as decreased cardiovascular function feeding into this terrible cycle where patients have a perception of a lot of difficulty doing any sort of exertion. And so this is like a vicious cycle that they can never leave because that leads to decreased exercise participation, decreased performance, and decreased reserve capacity, and so on. So it just feeds on itself. But heart failure, it's a complicated disease, obviously. Is this a rehab diagnosis? What's the role of a physiatrist here? Well, let's look at this a little bit closer. So heart failure was the second most common cause of hospitalizations in 2018, the first one being septicemia. And in a population over 65 years of age, heart failure is the most common cause of hospitalization. Patients with heart failure have also the highest 30-day readmission rates, up to 25%, compared to patients with other diagnoses. So basically, what we have here is an increase in financial burden in the US secondary to heart failure as well as across the globe. So right now, we have about 1 million of new cases every year, with a total of about 6 million in growing adults in the US diagnosed with CHF. Heart failure costs across the board reach up to $60 billion yearly. And this cost will grow and will probably exceed $70 billion by year 2030. Inpatient admissions comprise almost half of the total costs. And some analysis actually quote up to 80% of these costs being due to inpatient. But what's worse is that patients with CHF experienced horrendous quality of life. And in this particular illustration, showing that their quality of life is even worse than most cancers, or some cancers at least. So you can see the red bars in both physical component and mental component of the quality of life questionnaires show that heart failure causes decreased quality of life score than in cancers, such as lung cancer, colorectal, breast and prostate. Also, non-cardiac comorbidities that come along with advanced cardiac disease do play a role in exercise capacity and functional status in the overall picture of chronic heart failure. Specifically, obesity and diabetes, unfortunately, play a huge role in decreasing the ability to perform in six-minute walk test and demonstrate peak VO2 numbers. So definitely leads to overall quality of life and function. So we all know that cardiac rehab program can lead to improvement and health-related quality of life. I mean, there have been several articles published. And basically, we see that there is improvement in hospitalizations, even readmissions, and health-related quality of life with exercise-based cardiac rehab, no matter what type of cardiac rehab this is. So there's definitely a huge role in rehabilitation in general, in management of heart failure. The benefits of exercise, we probably are all familiar, but I'll list them here anyway. They're multifactorial, affecting multiple organ systems, but actually also having an impact on inflammation, inflammatory cascades, as well as metabolic processes. So the treatment of advanced heart failure can be multifactorial, but basically fits into three different categories, into either of the three categories. So palliative care is for those patients that are, for some reason, not candidates for more advanced heart failure management treatments. And the goal is to improve their quality of life. Patients may qualify for mechanical circulatory support, such as left ventricular assist device, which can be either destination therapy, if for some reason they're not candidates for heart transplant, or it can bridge them to the heart transplant, which ultimately is the treatment for end stage heart failure. So the challenge here is that patients can be pretty well managed with these either devices or a heart transplant in a hospital setting. But how do we get them from the hospital to home? So there are a few things that need to be accomplished. They need to have their medications optimized based on the guidelines. They may need IV inotropes and vasodilators. They can have the LVAD. They can have the heart transplant. And so we have a few discharge milestones that need to be achieved in order for these patients to transition to outpatient care. Those include, of course, medical stability, optimization of nutrition. Discharge medications have to be sometimes approved. They may be very costly. And so they may also involve home care services, such as infusion companies. Patients, of course, need to be able to ambulate and perform basic ADLs and IDLs and have a very solid follow-up and ability to actually get there, transport, and so on. And patient caregiver education cannot be overemphasized. This is very important for these patients to function in the community. So what are the benefits that rehabilitation in general can offer, and specifically acute inpatient rehab care? So while these patients are medically active, so to speak, but yet able to participate in three hours of therapy, they can then transition to acute inpatient rehab, where we can monitor certain things, such as orthostatic changes, bleeding. A lot of them are anticoagulation. Electrolyte abnormalities, such as we see with transplant patients who are on immunosuppressants, such as tacrolimus. Fluid balance, so IV diuretics. Oftentimes, aggressive diuresis is what they need. Nutrition optimization. Of course, reversal of effects of the bedrest. Learning compensatory strategies. Knowing how to prevent falls. Involving caregivers, of course. Heavy education. And setting up transition in care support after discharge, which should be accompanied by educating the family and the patient on how important it is to follow up. So can we actually administer exercise to heart failure patients safely? The answer is yes, we can. But we have to have very well-trained staff that knows how to recognize signs and symptoms of deterioration, how to monitor vital signs and certain parameters. There has to be significant team communication daily, multiple times a day, in order for each member of the team to know specific status of the patient's well-being or being on the unit, as well as great communication with heart failure or advanced heart failure or transplant team in order to manage medications and overall post-transplant or post-LVAD course safely. So I'm going to go specifically to the VAD management aspect. So with VAD patients, we have to be VAD, so ventriculosis device. We have to be careful about certain things. We have to know the anatomy and the new physiology that's involved. So these patients will have sternotomy scars. They will have a driveline. I don't know if you can see. I guess you can't see the marker. But basically, they have an inflow cannula from the left ventricle, outflow cannula into the aorta. They have essentially the motor, which provides continuous flow in between. There is a driveline, which provides power. And that penetrates the skin and the abdomen. That has to be dressed in a sterile way. And the dressing has to be changed daily. And family and patient need to be educated on that. The pouch on the belt is the controller, which has to be secured. And there are also portable batteries that have to be charged, obviously, and secured as well. And the power source has to be nearby. So as you can see, the device itself requires a lot of education. It's done over multiple days. It's not just a one-time sit down, you know, let's talk about this, look at the PowerPoint slides. So patients and families and staff also need to be aware of how to check vital signs. So it's not simple vital sign check. There's no real blood pressure. There are no cord cough sounds. We have what we call mean arterial pressure, which it's really not. But that's what we check in the brachial artery using the Doppler device. And we use a cough, of course. So there's a range. The safe range is about 70 to 90, with some variations. We have to monitor these patients for arrhythmias, although they have continuous flow, not a pulsatile flow. Arrhythmias are still important, because if there are tons of ventricular arrhythmias, it may affect the way the LVAD functions. These patients sometimes don't have a pulse, or they have a faint pulse, so don't be scared of that. And they have to be anticoagulated, because this device is obviously something that can lead to thrombosis and cause a stroke and other complications. So they have to be on Warfarin therapy lifelong, or at least for the duration of the device, with an INR goal of 2 to 3. All staff that's involved with the patient have to be trained with VAD management. So physiologically, LVAD, because of the continuous flow, changes the way the endothelium works. So the vascular endothelium growth factor is altered, levels are altered, as is von Willembrand factor release. Also, these patients are prone to have AV malformations in the GI tract. Add to that the platelet dysfunction and, yeah, platelet dysfunction and erythrocyte dysfunction, they are at risk for bleeding. And then we have to balance very carefully between the risk of bleeding and the risk of thrombosis, because both take place here. So patients are on Warfarin, goal INR 2 to 3, they have AVMs in the GI system, they have platelet dysfunction. At the same time, if the INR is low, they can develop thrombosis in the device, which can lead to strokes, which can lead to pump dysfunction and infections. So have to be very careful. This picture demonstrated here shows basically the thrombus in the device. We also have to be aware of the VAD parameters, of which there are four. Only one of them can be adjusted, that's speed. And it's essentially revolutions per minute, and it's the only parameter that's set. The flow is like essentially the equivalent of cardiac output. Power is work done by the pump. It can increase with clot or obstruction burden. And pulsatility index represents native contractility of the heart. So everyone has to be aware. And there are alarms on the display that can actually sound the patient, the families, and of course staff have to be familiar with what to do when the alarm sound. So what does rehabilitation look like with VAD patients? So again, education cannot be overemphasized, very important. There's always an LVAD buddy or caregiver that's closely involved and gets all the education alongside the patient. Patients sometimes present with encephalopathy, so it's difficult for them to absorb all this information, which makes it even more important to have a caregiver. They're not allowed to take showers or take baths, and so they have to have sponge bathing and chlorhexidine wipes. Basic operations of VAD equipment has to be taught to the family and patient, including putting on the vest and the whole setup, checking wiring, making sure it's not stuck on anything, checking parameters, know who to contact in case of an emergency or any issue. And they usually have the speed dial for their LVAD team close by. Patients benefit from rehab notebooks for education, handouts, goal setting, and tracking progress. They need to know about orthostatic changes and how to behave around these changes. VAD team usually manages Coumadin or Warfarin, I should say, with the INR goal of two to three. And these patients oftentimes develop depression, anxiety, understandably, and they need a lot of psychological support. So I'm listing everything else aside from the mobility and function aspect, of course, but all of these components are important in VAD management. And we start just like with any critical patient, we start with early mobilization, make sure VAD is secured, start with respiratory exercises and positioning, upper extremity exercise, progress to bed mobility and transfers, portable stationary bike can be used, and then progress to maybe getting out of bed and ambulation, light weights, elastic bands, and so on. And then when the patient is able to tolerate it and they can do a six-minute walk test as much as they can, or even better, CPAT, maybe in outpatient settings, of course, they can be assessed for functional capacity. The intensity really is determined by symptoms, though. It's not any particular number. We do use Borg scale rate of perceived exertion very often, which allows us to gauge how they're able to tolerate and where we're aiming in terms of intensity. All right, onto the heart transplant. So this is the ultimate treatment for advanced heart failure and in 2022, I just updated these numbers, so there were over 4,000 cardiac transplant performed in the U.S. alone, 51 heart lung transplants, again, in the U.S. in 2022, median age of transplant recipients is 60 years old, and life expectancy is a little over nine years. Again, we have to consider the new anatomy, new physiology for these patients, so they have a sternotomy scar, they have multiple drain lines, drain sites, sorry. The heart is denervated, so the vagal tone is lost, and so they present with resting tachycardia. Heart rate also adjusts very slowly in response to postural changes and exertion. They are in immunosuppression, they have to have weekly biopsy of the endomyocardium for the first four weeks, and then that kind of winds off depending on the presence and extent of rejection. They are at risk of infection, so they have to be on multiple prophylactic agents. Electrolytes need to be managed aggressively, especially because tacrolimus, for example, can leach out magnesium and potassium, and so IV supplementation is important. By the way, I found it very useful when I speak to the medical directors in insurance companies to mention that IV medications are gonna be taking place during patient's recovery, and so that seems to play a role. Rejection risks, so these patients are at risk for rejection, of course. They're at risk for ischemia, but ischemia does not present the usual way. They don't present with a typical chest pain. If they do have chest pain, it's probably not from ischemia, it's from musculoskeletal causes, you know, pleuritic causes, other causes, but rejection and ischemia can present a sudden onset heart failure, so low extremity edema, sudden onset shortness of breath, decreased exercise tolerance, and sudden onset arrhythmias, so that needs to be explored. Following heart transplant, so patients present with a lot of debility, so muscle weakness, loss of muscle atrophy, so cardiac rehab is important pre-transplant, just like with lung transplant patients, as well as after heart transplant, so because these patients have abnormal or unusual heart rate response, so it's probably not useful to have a regular stress test, so it's great to use a stress test that involves metabolic study, CPET, and six-minute walk test, more functional, and I think will give us more information, BORC score system is used to gauge the intensity of training, so we can start with 11 to 13 on a scale of six to 20 BORC scale, and progress to 13 to 15. Early mobility and aerobic exercise kind of counter the effects of sarcopenia and bed rest, and the emphasis again is on patient education, caregiver education. Comorbidity, so again, I found it useful to look for those things, because they're inevitably present and complicate the whole recovery. So patients who receive heart transplant oftentimes are critically ill for long periods of time, so they may present with sequelae of critical illness and ICU stays, such as neuropathy and myopathy. They can have peripheral vascular disease with limb ischemia, leading to amputations because of pressors that are used in the ICU, kidney disease leading to hemodialysis or even the need for kidney transplant in the future, liver disease, neurological sequelae such as encephalopathies and CVAs can also be common. Press syndrome is something that I don't see very often, but I have seen it a couple of times, is also a type of encephalopathy, and musculoskeletal sequelae such as severe pain, loss of muscle, osteoporosis and osteoporotic fractures, infections, metabolic abnormalities, and bone marrow suppression from immunosuppressants, which leads to pancytopenias. So, advanced cardiac disease can be treated and I think it has to be multifactorial and I think rehabilitation is a huge part of treatment for these patients, which needs to be available, needs to be made available to them. Discharge from the hospital has to include, I wrote should, but it has to include physiatry, follow up in my opinion, and transitions in care is basically great when it involves rehabilitation because we can additionally monitor these patients on frequent basis, we can continue to educate them, we can help them reintegrate into the community, and we can provide the frequent follow up that they need with therapy sessions, and most importantly, we can empower these patients to get more motivated and get back into their normal lives. Okay, my luck changed. Here we go. Thanks for all staying the course. I'm going to take us home, and I hope not to go over time. I know 5 o'clock is a bewitching hour. I'll do my best. I'm Jonathan Whiteson. I work at Rusk Rehabilitation with Sophia. And I'm one of the professors of Rehab Medicine and Medicine at NYU Grossman School of Medicine. And I'm going to skip through my learning objectives because hopefully you're going to learn. And I want to save time. I have nothing to disclose. Skip through my overview. I like this slide. I like this graphic. We're the little red person. We are steps ahead. We're steps ahead of our colleagues. Why? Because we think in a very global perspective. And us as physiatrists in this field of physical medicine rehabilitation, we think ahead of the game. And we think in a collaborative manner. And we think in terms of a team perspective. And all of these points here, bundle care initiatives, value-based care, early mobility. I mean, some of these have been mentioned. I'm going to go over them again. A dedicated physiatric consult service, physiatrists and nursing facilities, what we've done in the COVID and PASC space, DEIA initiatives, how we innovate technology. Gosh, that plenary session at lunchtime. Wow, that tells us what the future is going to look like. Our engagement nationally and internationally, this is what we do as a team. And cardiac rehabilitation, pulmonary rehabilitation exemplifies everything that we believe that we are as physiatrists. If you, if your department, if where you work doesn't have a cardiac rehab program or a pulmonary rehab program, come talk to us. We're four strange physiatrists. But we are all very experienced and very much involved in cardiac and pulmonary rehab. And we hope that you have an interest too, which is why you're here. But we realize this collaborative is not just with you in our departments, but with health system executive leadership, with community organizations, with local national PM&R departments and organizations, but specifically with our patients and their families. We're talking value-based care. And again, you've heard of what the triple aim of health care is in terms of improving outcomes, improving the experience of the patient, and improving the efficiency. We're doing more for less money, essentially. But this is very important to our health care system. And as physiatrists, we exemplify value-based care. And cardiac rehab, pulmonary rehab is absolutely along for the ride. We want to be home. We don't have ruby red slippers. But if we did, we would click them. But this is where we want to be. We want to go from our acute care setting and our hospital setting into our outpatient centers and into the community. That's the goal. That's the role that physiatry plays in value-based care. This is what we are expert in. And we need to think about how we do this. So I'm going to share with you some of our experiences from NYU, from Rusk. And I'm going to go back a number of years. In fact, I'm going to go back close to 2009, where we started to get wind of the Bundled Payment Care Improvement Initiative, which came into law in 2013. Why was this an issue? Because the BPCI bundled payments for many kinds of cares, particularly from this perspective in terms of cardiac care. Cardiac surgery was going to be bundled into one payment for an episode of care, which included a few days before the admission, to 90 days afterwards. So that meant that inpatient rehab was considered, oh, maybe expensive and therefore expendable. Outpatient rehab, which should happen in that time period, oh, maybe expensive and expendable. So how are we going to deal with that? Our experience at NYU was most of our patients who had heart surgery came into Rusk. We were able to do it. We took good care of them. They did really well. But we realized when this BPCI program came in, we weren't going to be able to do that. So we needed to think again. So we partnered with our cardiovascular surgeons. We flipped the culture. Rather than everyone coming in, we said, everyone should go home, and let's see what we can do to make that happen. We knew we needed to put our therapy not in the acute inpatient facility, but in the acute care facility. So we needed to enhance our therapy services in acute care. We needed to partner with home care agencies. Many of these patients were going to bypass inpatient rehab. They were going to go straight home from the hospital. Home care agencies needed to be up to speed. And then we needed to get them rapidly into an outpatient program, which, if we didn't do inpatient, the surgeons would agree and the administrators would agree to the cost. It's actually not that expensive, a few thousand dollars. So, you know, as well as joint replacement and spinal surgery, our institution, NYU, were looking or participated in the cardiovascular surgery. But this was the outcome of our initiative. This was the outcome of our collaboration and our flipping the culture. You see, 2009, 65% of patients who went through cardiac surgery came for inpatient rehab. 65%. By 2013, when the program became active, down to 20%, an increase of, went further down to 12%. All these patients were going home. So by flipping the culture, by enhancing our acute care services, by working on this value-based care model, by rehab being absolutely integrally involved in this process, we reduced length of stay and we reduced post-acute care. What about the role of physiatrists doing consults on our cardiac and pulmonary patients? Well, again, our experience was that many patients who were coming into our cardiac and pulmonary and our transplant rehab floor had long lengths of stay in the acute care setting. Why? Because there was limited understanding by our acute care providers about what our physiatrists could do in their scope of practice. We had an underdeveloped consult service and we didn't have any data to track and keep ourselves accountable as to what we were doing. So we said, well, we need to educate our acute care teams and that's what we did. We spoke with the cardiologists and the pulmonologists and the surgeons and the transplant team about what we could do as physiatrists and as a PM in our department. We established our consult goals for our physicians doing consults, how quickly we wanted them to do those consults. We made our physiatrist consult service sort of almost like a dedicated job, that this is what they would be doing week in and week out. We actually have two physicians who work on our inpatient service. Actually, Sophia is one of them. And they do one week of inpatient rehab on the rehab floor and one week of consults. We also worked on the consult content template of what was being included and we developed tools to track the metrics. So what did we start to see in terms of what our consult service looked like? Well, we knew our physiatrists could go to the bedside and work on our patients who had pain. They could work on the cardiac and pulmonary precautions. They could help understand and monitor the vital signs and oxygen needs and guide the therapists in terms of how they were managing the patients. They could work on disposition planning. Should this patient come for inpatient rehab or are they going to be well enough in a few days to go home or do they need a skilled nursing facility if it's not on earth? And then work on building programs. And you've heard this term ICU early mobilization program and I'm going to go into some metrics on that. And also we developed our transplant program. In the last five, six years, we've had a rapidly developing transplant program and we needed to address the needs partnering with our transplant surgeons and physicians to make sure that our acute care transplant rehab program was up to speed to help the patients get where they needed to go. So we needed to track data as well and this is some of our dashboards in terms of how we're tracking the data. And this is some of the data we look at in terms of the time it takes for our patients to be seen in consult and the median and average hours as well. And we set targets to make sure. But this data tracking helps us keep accountable, helps keep our individual physicians accountable as well because they see this data too. So what about an early mobilization program? So we heard Dr. Bartels talk about that as well and Sophia works in this space too. But our experience was that patients who were in the intensive care unit had long lengths of stay. And when they were there, they were functionally stagnant at best and most of them were declining. We noticed that each team that took care of a particular part of the body, the kidney, the brain, the heart, the lung, the skin, they all rounded individually and none of them collaborated with each other. Patients were confused and agitated. They have abnormal sleep-wake cycles. Their care culture was, let's have the patient survive today but they didn't think about tomorrow where the patient was going. That was our role to think about that. And there was really no collaboration with executive leadership in terms of planning. How could we improve this? So what did we do? We as a department, a physiatric department, a PM in our department, we said, let's collaborate, let's get together and we changed the culture and we helped develop an ICU team that was primarily responsible for the patient. The ICU team took care of the patient. Everyone else came and consulted but gave advice and guidance to the ICU team who made the decisions and managed the patient. We addressed sedation and delirium, sleep-wake cycles and pain so that when our therapists went to see the patients, they could actually get them up and mobilize them because they were awake, they were alert, they weren't delirious, they weren't in pain. And we changed our culture to believe that patients were going to survive the ICU, they were gonna go on to the hospital units and then maybe rehab, but we needed to take care of them throughout that whole perspective and we needed to mobilize them early. The sooner we got them up, the less deconditioning, the less functional decline, the better they were. And we needed to get executive buy-in as well. We knew that putting in a program like this would require dollars, dollars up front, would that translate into savings down the road? It was a leap of faith, and the patient went with that. And sure enough, the outcomes were stellar. In this trial program that we initiated, we saw close to a day reduction in length of stay in the ICU, close to two days reduction in the med-surge floors and a 12% reduction in cost. More patients went home, more patients went home without services, fewer patients went to acute rehab, sub-acute rehab or to a nursing home, which is good. It's good. Patients should be going home, just like those ruby red slippers. That's where we want our patients to be, to get them home. And sure enough, there was a significant cost savings. So the administrators loved this. They recognized that their upfront spending resulted in significant savings. And we published a paper back in, what is it, 2019, excuse me, 2017, documenting that. More recently, we've had this growth of our transplant program, and we initiated another project looking at rehabilitation services and how we could enhance the recovery following heart and lung transplants. This was initiative, again, that Sophia and her team were involved in and showed significant dividends. The number of patients requiring acute rehab dropped from 49 to 34%. Those patients going home significantly improved and length of stay reduced by over a day. So again, the impact of a coordinated and organized rehabilitation program that's run by physiatry, that's integrated in the acute care setting with our transplant teams, paid tremendous dividends. So what about hospital throughput? That's really important. We look at length of stay, we look at another metric called observed to expected length of stay. That relates to not just how long patients stay, but also relates to their expected length of stay based on diagnosis, comorbidities, and a calculation that's done by mine's way more brilliant than mine. I couldn't tell you how they calculate it. But that metric is really important to hospital administration and really shows value. The lower the number, the better the value. So our experience was, again, that admission to our inpatient units was delayed, it was slowed, and there was a discordance between what we called medical stability as a rehab team and what the acute care teams called medical stability. The referring team weren't clear on what services were available at the Rusk sites. And the consulting clinicians, when the patients came over to Rusk, they didn't follow them consistently on our Rusk units. And this was a big issue in terms of a barrier to getting patients over in a timely manner. So what are our solutions? Well, we needed to improve our communication, we needed to educate our acute care partners in terms of what were the medical issues we could and could not take care of. As Sophia said, we would take care of patients with VADs, we could take care of patients with inotropes, et cetera. So this was revealing to our acute care teams. And we also made sure that all consulting teams actually did follow up with patients on the acute care service. And our transplant team agreed to round on our patients every single day. We didn't need to call them. They just came. They rounded our patients every single day. What about skilled nursing facility? Where does that come into this sort of value-based care and this throughput through the hospital? So again, our experience was once Sophia or any of our other consulting physicians went to see the patients, all the patients wanted to do was come to Rusk. Even if they weren't appropriate for an acute rehab facility, they saw Sophia, saw our team, saw our therapist, said, I'm not going anywhere else. And that obviously isn't going to be good for every single patient. There were mixed messages to the patients. Sophia may say, you're going to go home. One of the acute care social workers may say, well, let's get you into Rusk. One of the medical teams said, we're going to send you to a skilled nursing facility. Lots of mixed messaging. And that was obviously a problem. There was a concern of the quality of care at our skilled nursing facilities in the region. And then we didn't have continuity of care. We didn't have our NYU docs going to those skilled nursing facilities. Well, what was the solution? Well, if we couldn't bring the patients to us and we were going to put them in a skilled nursing facility, we needed to build a preferred partnership, educate our skilled nursing facilities, even build a cardiac rehab program in our skilled nursing facilities, which we did. I worked there. Sophia worked there. We have an active cardiac rehab program at a skilled nursing facility. It's very effective, very impactful. And we wanted to make sure that our physiatrists were in our skilled nursing facilities so that patients would know, they would have confidence that they could see our physicians there. And so we were successful with putting our physiatrists into those skilled nursing facilities. And we've also now extended this program to include our residents going to our skilled nursing facilities. This is the program that we built at the New Jewish Home, which is in the Upper West Side of Manhattan. And again, it's a very well-utilized cardiac rehab program. So what about some of the data, the metrics that we need to look at in order to say, look, this is a value. This means something. This is how we track ourselves. And this is how we justify our existence. So this is a heat map. Red and orange are not so good. Yellow and green are better. I'll convince myself that as we go down, we're seeing more yellow and green and less red and orange. I hope I can convince you, too. But that's the goal. That's what we're working at. And these are some of the metrics that we're looking at in terms of, how long does it take to consult a physiatrist? How long does it take that physiatrist to complete their work and their consult? How long does it take to have concordance between the medical and the physiatric medical clearance? And how long does it take to get insurance clearance? And so this is the length of stay. This is just the raw length of stay data. When we're looking at our patients who are coming to cardiac rehab and pulmonary rehab. And again, I'm trying to convince you. But I think the data does show that this is a significant regression analysis. But we are seeing a decline in length of stay of patients when we have our teams involved in these patients. Now, this is the metric that really counts. Over the last four fiscal years, when we look at our observed to expected length of stay, this is the hot data, the hot metric that our hospital administration look at. It's on the dean's dashboard. For patients coming to Rusk, our O to E used to be two four years ago. And now it's down to one. So this is a significant improvement in terms of length of stay based on our physiatric intervention. You've all heard of the 60% rule. You'll recognize that those patients who have cardiac and pulmonary disease often are non-qualifier in terms of the 60% rule. We have a very active cardiovascular pulmonary program and transplant program. And so we were running into issues. We started to notice that our data, in terms of who was coming into rehab, a lot of these patients were non-qualifying. We were flying close to the sun. And so we needed to re-educate our physiatrists, re-educate our whole teams, track the data, make sure that we were all accountable. And you'll see here that we got as low as 62.4% in terms of fiscal year 2021. But with this re-education and refocus on documentation and recognizing comorbidities, we've actually improved our data. And we have a very vibrant admission policy for patients with heart and lung disease because we're able to document and show that they do fit in the 60% rule. But this is something that all inpatient rehabilitation facilities need to be aware of. What about getting patients from the inpatient rehabilitation facility to home? Very, very important that we're focused on this and bringing in complex patients with advanced heart and lung disease and VADs and on inotropes and transplant patients, getting them to go home as opposed to a skilled nursing facility. That's a challenge. And of course, that's our goal. We want them to come to IRF and then go home, not go on to SNF. But we did notice that many of our patients were going on to SNF. We knew we were admitting complex patients and that they had complex social issues as well. And discharge planning was a real challenge. So our solutions, we needed to communicate with our acute care teams. We needed to work with our social workers and case managers and work with our patients and families. We felt that we could increase our length of stay in the acute rehab facility in order to improve them functionally and minimize any medical issues so that we could hopefully get them home. And we set a goal. We said, let's send three out of every four patients home. Let's set a goal of 75% to home. Let's work towards that. In terms of readmission reduction, so it's our experience that patients who are coming to the cardiac and pulmonary rehab floor were having a very high rate of readmission, well above the national average. And when we looked at our transplant patients, well above are well above. I mean, it was really very significant. I'll show you the data in a moment. And again, we understood we were accepting complex patients and we were accepting them early. But we had a significant readmission issue. So again, we said our transplant teams, our consulting teams, they needed to come at least, well, not at least. I mean, daily for our transplant, but as often as needed for our other patients. We worked on a policy of treating patients in place. So patients would go into atrial fibrillation. We would try to treat them in place on the rehab floor. If we could, if we could manage them, even if they needed a day off of therapy and convert them back to a sinus rhythm or a rate control, we would keep them on the rehab floor. And we had this culture change throughout. Let's see what we can do to keep them on the rehab floor. This is the data on the left hand. The left hand part of the plate is our readmission data from our cardiac and pulmonary rehab floor, either from the floor or within 30 days of readmission. You can see it's quite significant, 20% to 25%. But for our transplant patients, even as high as 40%. This is a very complex population. We've not won this battle. We continue to work on this battle to reduce that readmission rate. You can see from this panel that we've actually, the orange bars are the length of stay. We've purposefully increased the length of stay. We're looking to see if home discharge increases and whether readmission rates decrease. We're still following that data, still a work in progress. Transitional care management, I know I'm going over time, forgive me, I'm gonna be as quick as I can. But transitional care management is a program whereby we have enhanced care management after a patient has been discharged home. The data looking in the general medical population shows that patients who are treated in a transitional care management program actually have a reduced readmission rate. We noticed we had a high readmission rate. We said, is this transitional care management program gonna be good for us? So we've implemented a TCM program for all of our patients. Our goal is every single patient who goes home gets enrolled in the TCM program. They have to have a phone call from a nurse within 48 hours. They have to have a visit with a physician or a nurse practitioner within two weeks and the care coordination goes on for 30 days. And you're gonna see that our number of patients who have had transitional care management visits has increased and that our discharge rate for those patients who've had transitional care management has reduced. So this is an effective and impactful program for the physician who sees the patient, the RVU reimbursement is significantly enhanced over a regular visit. So a TCM visit pays dividends both in readmission reduction, which is great for the patient and for the institution, but also for the physician as well. And this is data directly from our cardiac. The initial data I showed you was our general data and this is from our cardiac rehab patients. And again, showing the reduced readmission percentage for those from our cardiac and pulmonary rehab floor that have had a TCM visit. I think very close to my last slide. Again, this is value-based care at its best. This is the role that physiatry plays in the acute care setting, in the hospital throughput setting, in the IRF setting. If you don't have a cardiac or pulmonary rehab program, I think the data that we've presented today, the discussions that we've had today really do show that this is a value, not just to you as an individual physiatrist, but to your department, to your health system, to your hospital that you work at, and absolutely to your patients. It takes strategy, it takes planning, it takes communication. Those were my learning objectives. I hope I've achieved them. And I will thank you very much for your time. Sorry for going over. Thank you. Anyone wants to ask questions, you can come up to the microphone. the entire panel, it was an excellent presentation. My question is based on the last component of the presentations on value-based care and integrating it with assisted living centers and with long-term care. Have you had any experience as you're partnering with healthcare institutions once the patients are discharged in SNFs and sub-acute and are transitioning to long-term care in having a translational cardiac rehab, home rehab, home exercise, maintenance program, or have you had any experience with that? If not, can you comment on it? Yeah, so assisted living, no. Long-term care in terms of a patient in a skilled nursing facility transitioning to a long-term care bed, yes. And our physiatrists see patients in the SNF and also in long-term care. And of course, we're instilling in our patients that activity slash exercise, this rehabilitation philosophy is not just for the duration of the time that we're seeing you, but is lifelong. We give them the tools, we give them the culture and the philosophy that they keep going with what they're doing. But I think you're right. I mean, we haven't looked at assisted living and we haven't focused so much on the long-term facilities of nursing homes. But these are opportunities that I think you raise a very good point. Matt, David, thoughts? We also haven't done anything with assisted living, but I think that essentially anywhere that these patients are, there's opportunities for them. And I forgot to include, when we talk about 30-day readmission rate or readmission, the opportunities are in the outpatient setting, right? Because what happens in the hospital stays in the hospital and the work of keeping them out of the hospital is actually an outpatient responsibility. So I think that there are lots of opportunities wherever the patients are. Is that a setting that you work in? Yes, partly. It's nudes for me, so. I agree, we don't have any. Thank you so much. Thank you.

advanced medical rehabilitation

patient outcomes

pulmonary rehabilitation

lung transplant

exercise capacity

advanced heart failure

cardiac rehabilitation

quality of life

post-transplant care

data collection

team communication

lifelong exercise