In this interview, we talk with Kate Treynor, RN, MS. Kate began her career as a nurse on the general cardiac floor of a small community hospital where she quickly found herself gravitating towards cardiology and cardiac nursing. She then began work in cardiac rehabilitation at UMass Medical Center in the early 80’s in a multidisciplinary program. Kate found herself wanting to take on a leadership role and enrolled in graduate school. Shortly thereafter, she became a Cardiac Clinical Specialist in Providence, where she implemented a cardiac rehab program. After a few years in Providence, Kate went to Mass General Hospital in Boston as a Clinical Specialist where she rose through the ranks at MGH and became Director of Cardiovascular Disease Prevention in 1992.
Kate holds a position on AACVPR’s Board of Directors and fills us in on how the Roadmap to Reform initiative helps facilitate the current shift to value-based payments. She details the inception and implementation of her primary prevention program at MGH to manage cardiac risk. MGH’s primary prevention program uses a high-human-touch approach to encouraging lifestyle changes in the management of cardiac risk, Kate talks about the studies that support it. We conclude the interview on the subject of legislative and policy changes that would help cardiac rehab centers achieve their full potential within the full spectrum of cardiac care.
MA: So Kate, it’s nice to see you’ve been in all aspects of cardiac care, all the way from the floor to in-patient, to out-patient. Currently you are involved in both primary and secondary prevention programs. Can you tell me, how did you convince your hospital, to implement such a primary prevention program given there’s possibly no reimbursement?
KT: So this is really an interesting story. We had a patient in our outpatient cardiac rehab program, that thought that the physical plant where we were located was wholly inadequate. So he put up a challenge grant to the hospital and said he would pledge a certain amount of money if the hospital could match that. Then if the hospital raised some more, he would then give a second amount of money. It would give us a feed of about a million and a half dollars to create a new center. So we wanted to be able to approach donors about the reason we were wanting this new center. In order to get people excited and get buy-in, we wanted to create a vision that everybody could relate to.
Part of our vision was to come together, myself and the Cardiology Director here, the Medical Director, and really lay out where we thought we could be the most effective. We already knew that we had a robust secondary prevention cardiac rehab program, but that managing cardiac risk and reducing risk is really what we need to do. Sort of pull the camera back and help people before they even got to the point of having heart disease. 90% of what leads to heart disease is lifestyle. So we thought if we could begin to work with patients who were at high risk, meaning they had a high family history, or they had risk factors already, they may already have some motivation to want to make some changes.
So we presented that as our vision, really as a part of an overall full spectrum of cardiac care. That dealing with patients at risk, as well as patients already with disease, should be part of that vision, that overall full spectrum of cardiac care. So that was how we did it, and that was what sort of brought us to create the vision. We were pretty successful in the fundraising as a result.
So we implemented this primary prevention program that we called Heart Attack Prevention, and we tried to choose words that people would understand. Because you and I can talk about primary prevention, but the lay public doesn’t necessarily understand that. If you say “heart attack prevention,” that certainly has more meaning. We targeted specifically young people at high risk because of a family history. We also used the term metabolic syndrome, which was for patients with risk factors already.
Patients that have high cardio-metabolic factors that were going to lead them down a path to develop disease, whether that be diabetes or heart disease or both. So we had now three programs in the center that we were targeting three distinct populations of patients. Those at risk, because of their genetics or family history, those at risk because they had risk factors that placed them there, and then thirdly, those with disease which is the cardiac rehab population. All of the things that we do in those three programs are very similar, because it’s really about helping people to make lifestyle change to ultimately reduce their risks.
MA: Right, and as you said, "90% of heart attack prevention is lifestyle”.
KT: Absolutely. There’s a fabulous study called The Interheart Study, which in a 15-country international study that was done, that’s where we really understood clearly, that in no uncertain terms, it was lifestyle that was really making the difference.
MA: That’s also interesting that you say that because, it would also point to sort of rare, out-of-box conditions at management level, that we have to direct our resources as a society, if you want to prevent expensive heart attacks, surgeries and interventions in the long run. I seem to think there’s a lot of generalizable lessons. That’s basically what you are implementing.
MA: So, what barriers have your patients experienced, both in your primary and secondary preventions, when making those lifestyle changes?
KT: So, what’s interesting is for the patients that are primary prevention, many of them feel that because they have genetics that put them at risk, it’s sort of a fait accompli. What we try to tell them is that you can’t change your genes, but you can change your jeans size. Really, not everybody with a family history develops heart disease. And why is that? It’s probably because they managed their affairs a little more effectively.
So I think that a number one reason in the primary prevention population, is to help people understand that. That it isn’t necessarily fate that it’s just going to happen. They actually can exert a lot of control over that, and need to exert a lot of control. The other is, it’s very difficult for people to change behavior. It’s easy to have bad behavior. So for instance, when somebody has disease or they have developed a health issue, and we suggest that they take medications, or you know, go for these therapies, those are easy because they’re add-ons. But to say to somebody, “you know, you need to lose weight. You need to stop smoking.” Those are more difficult and more challenging for people. So, really getting people to step back and change the way they do things is where I think the most difficulty and the biggest challenges are.
MA: Yes, I think it’s always easier to swallow a pill than to exercise 45 minutes a day.
KT: Absolutely. A lot of people are ambivalent. They want it, but they don’t necessarily know how to go about doing it and where to start. For instance, when it comes to quitting smoking or changing your diet, many patients have started that and failed, and feel like it is something that is just not possible for them. It’s really trying to find the right key for that lock, so that you can get in, unlock it and begin to work with that person a little bit more successfully.
One of the things that we use that has been highly effective, is a technique called motivational interviewing, which is when you’re thinking about helping patients to modify behaviors. The interviews are about working with patients to engage them in a process. So this approach is about the plan coming from them, and working with them to find that plan, and make it theirs. So it isn’t about knowledge. It’s not about education. Certainly you do educate patients, but people know that smoking isn’t good for them. It isn’t really that they lack the knowledge. It’s that they lack the confidence or the skills to know how to go about implementing a successful plan.
KT: Motivational interviewing is a goal oriented, client-centered behavioral change approach. You’re working with them to help them find what they think will be most effective. You resist telling them what to do. You try to understand what their motivations are for wanting to make the change. You have to be very empathetic and listen carefully. Affirm and reaffirm that what they’ve said is what you’ve heard, and make sure that you’re repeating back to them what you’re hearing. So they say “yes, that in fact is true.” And then help them to set achievable goals, identify the barriers, and come up with a plan to kind of navigate around those barriers.
MA: That makes sense. It seems like that approach also means you’re getting them into the habit of, let’s say one day in the future, you know, they’re not part of your network or hospital, they still have a habit of “Hey I need to set a goal, this is how I set a goal and this is how I think through achieving that goal.” Promoting their self efficacy.
KT: Yes, absolutely. That’s what it is. It’s getting patients to be thoughtful about the process and disrupt their ambivalence a little bit. Many people want to quit smoking, or want to lose weight, so you have to kind of help them understand the advantages of losing weight for them, and what are they giving up in order to lose that weight? So what are the cons for them? It’s helping them to think all of that through.
MA: Do you have any sort of stories or anecdotes of how people have responded to this kind of motivation…Before and after stories at the end of it?
KT: Sure, I mean certainly it’s always by trial and error. As a young professional, you’re always wanting to just tell people all of the facts and let them know why they shouldn’t smoke, and what the bad things are about smoking. And, of course, that doesn’t help them really to quit successfully.
So really, you know, there was a young gal, you know, that came in that was a smoker, and she was really having a hard time quitting. So we were talking about, kind of, what it would mean for her to stop smoking, and what gets in the way. And part of it was that she was afraid that she would gain weight and, and that was something that she didn’t want to do. So we were able to work out a strategy where she laid out her plans, you know. And I affirmed for her that, made sure she understood the facts. That the data really says that there are 30% of people that gain weight when they stop smoking, 30% stay the same, and 30% can actually lose weight. So we talked a little bit about, since those were her concerns, how might you offset that? Where do you think that would happen? So if you get a craving for cigarettes, how do you think you might be able to manage the craving without turning to food? All of those kinds of little tips. Ultimately, we got her first to cut back, and then she did eventually work her way all the way through to quitting, and without gaining any weight. So she was pretty excited about that. You know, it takes time to do that, and to help people feel like they have a solid plan.
MA: Yes, it’s a lifetime of choices that you are battling against, right? So it’s not as simple as “Okay, I’m stopping eating red meat right now.” It’s something that you have to work against a little bit of psychology as well.
KT: Exactly. A lot of times when it comes to things like drinking, you know, people drinking an excess amount of alcohol or smoking, a lot of times, those are the drugs that are treating, as you mentioned yourself, an underlying mood disorder. So you kind of have to understand that. If you’re going to remove or suggest removing the drug of treatment, which is either nicotine or the alcohol, then you have to have a strategy for helping them manage the mood disorder that will manifest or surface a little bit more acutely.
KT: So, you’re right. I mean, there is a lot of, sort of, interplay between the behavior and the psycho social component as well, and understanding that interplay.
MA: It sounds to me that the complex nature, that the role of the nurse practitioner or the nurse is really critical in all of this.
KT: Right. Right.
MA: As a friend, philosopher and guide to the patient…
KT: Yes, anybody that’s working with the patient needs to have a pretty good command of how to effectively help affect behavior change. So even the nutritionist. You know she’s decided to work with somebody on changing their diet if they’re diabetic, or if they need to lose weight, or even, you know, eating more healthily, you really need to understand. They need to understand and work with somebody around what somebody’s own goals are, and what prevents them from being successful. You know food is a very emotional experience for a lot of people. So I think the nutritionists, as well, need to be quite skilled in this area.
MA: Going back to your earlier comment, I think that it might be a disciplinary team. It’s not just about about exercise. It’s also about the psychology.
KT: That’s right.
MA: So briefly changing track. What we’re hearing a lot about now is how cardiovascular services will be affected by the new models. How do you see all the learnings that you have and your set of services, sort of evolving and changing tactics to cater to the needs of such models? More generally in terms of your skills and your and your team’s skills?
KT: So I think that the first we need to understand why we even need to think about this. That certainly, people aren’t going to engage in a process to make changes unless they feel a part of the process and that they need to make the change.
So really the whole shift in reimbursement is to more value-based care, and more value-based outcomes. We’re going from simply providing services and getting paid, to people really looking at the difference that what we do makes and basing payment on that. The bundled payments are one way to begin that process of shifting from the fee-for-service world, into kind of a value-based world. Whether or not these bundles go forward, or how they go forward is subject for some discussion. It’s really about understanding the landscape is changing.
We need to be able to show what difference we make, and how we help improve patient outcome. In order to do that, we need to be able to see more patients. We need to engage with them over a period of time, you know? Because, data tells us, the longer we’re engaged with patients, the more effectively they make and maintain changes. But most programs are not going to get additional resources from the same point of resources. I mean staff, human resources, because that’s an expensive undertaking. So it’s really thinking about how can you work more effectively and efficiently with the same number of resources, but perhaps touch more patients and have interaction with more patients.
KT: So we need to begin to think about getting more patients to programs. Getting more patients enrolled in programs and then interfacing with patients or a program for a longer period of time. And if you have a fixed set of resources, you have to think about each of those things a little bit differently.
MA: Makes sense, could you go a bit more into detail?
KT: Of course, so for instance, in the old days when we start with referral, we would perhaps be able to go into the hospital and meet the patients. That just doesn’t happen anymore. So, you know, we are now, most of us, fortunate to have these electronic medical records or health records. There are mechanisms within those systems to automate referral to cardiac rehab.
So that’s really the first step. If you don’t know about the patients, you can’t help them. So the first step would be to try to have a more automatic process for getting patients, to have you alerted to them. Then, once you get those patients and know who that cohort is, you have to really start to think about interfacing with them. The sooner you do that, the more likely it is that they will end up in your program, or perhaps a program that may be geographically more convenient for them. The longer it goes between the period where they leave the hospital and you contact them, the less likely it is that they’re going to enroll. So the focus then needs to shift from the referral process to the enrollment process.
There needs to be a reach-out and a touch to that patient as quickly as possible. And then lastly, it’s getting patients to programs. If they want to be successful, it has to be convenient and manageable, and remove as many barriers as possible to getting them enrolled and active in a program. That’s where you need to either direct them and help them get engaged with a different program, or engage them in your own program and think about creative ways of working with them. Then, you at MA know, better than anybody, sort of the notion of using some augment to do that. Whether it’s the kind of creative telehealth platforms that you’ve created, or virtual visit technology. But some creative way, you know? Even helping patients to track themselves with their cell phones. Many of them aren’t aware that this capability exists on their smart phone.
Whatever it is that you can help them to do, apart from them physically coming into the center, will help them perhaps continue to track themselves, and then provide you with data that you can give them feedback on. We need to approach the problem from all three vantage points.
MA: Totally agree.
KT: There are patient barriers and there are system barriers. And you know, sometimes in cardiac, one of the biggest challenges is ourselves. Sort of being stuck in many ways. One being old ways of doing things, in that this is really the time that we do need to start thinking out of the box. The world is changing around us and unless we change to accommodate some of that, we are going to be left by the wayside. So programs really need to step outside of what they’ve always done, and think creatively how to get more patients in, and work with them a little bit more effectively and creatively over a longer period of time. So that would be sort of a system and a program-related change, I think.
The second is to kind of step out of this mode, you know, “we’re just a small program that gets no respect.” I once had a Medical Director joke and say that cardiac rehab was the Rodney Dangerfield of cardiology. I really believe that if people can step forward and begin to talk a little bit more effectively, invest in partners in the hospital and their facilities, they’ll come to find out that their input is valuable, and people do appreciate it and understand the difference that they make.
So I think it’s just encouraging our professionals to begin to do more of that. From a patient’s standpoint, there’s lots of barriers. There’s socioeconomic barriers if patients have co-payments and limited incomes. Certainly, that’s a challenge. Creating new programs like hybrid programs can sometimes help adjust that a little bit. There’s the barrier of getting into programs, whether it’s transportation or parking, depending on the location of the program such as ours, which is in a big city with expensive parking. Certainly that’s a variable. Then there’s the barrier of just getting patients to believe that they can make the changes and that it’s worth their time and energy. So, you know, all of those things need to be considered.
MA: So I know you’re doing well with the R2R initiative from AACVPR. Could you briefly describe what rehab centers can hope to get from the R2R initiative?
KT: Right. So you know, of course, the R2R Initiative, which is the Roadmap to Reform, is to help programs really understand what this whole shift in healthcare reimbursement is, and how the focus now has now gone to quality from quantity. So it’s in response to the CMS Center For Medicare Medicaid Innovation who created these bundled payments for certain categories of cardiac patients, those being the AMI patients or heart attack patients and the Cabbage patients. Patients undergoing coronary artery bypass graphs, we wanted to prepare our practitioners in the field to both understand what was happening, and more importantly, recognize the implications for them.
The way that CMS had set this up was to divide this into four distinct categories. So in addition to bundling payments for patients who have AMI or Cabbage, they also superimposed this hands and glove as an incentive for referral, and getting patients into the cardiac rehab programs across the country. They were very creative in the way they went about thinking and doing this. They designated certain areas of the country where these bundle payments would be in effect, and then chose four separate strategies for the cardiac rehab incentive. So they basically paired up some regions with bundle payments and the incentives, and some areas of the country with only the bundle payments without an incentive for cardiac rehab.
And then there are patients in sections of the country that received the incentive only, and continued in the old fee for service, or pay as you go, if you will. And in the fourth category was no change. So, just sort of the programs continuing to deliver the services get reimbursed for them as they currently do. So our strategies in the R2R Initiative were to help programs understand, depending on which of those four arms they were designated to be in, to think about strategies. What the implications were for them, and then to think about strategies to work effectively with administrative and physician counterparts to work quickly to respond to those. So we did it through a variety of ways.
We started with mostly webinars to educate them, and then moved to specific strategies for how to dialogue with administrators and doctors. Then we focused on processes that they may think about changing in their programs and responding to increasing volume, and how to make efficiency changes in the programs. There has also been monthly email communications to try to educate them more, and help them understand, as well as keep them updated on changes in relation to this whole reform that we’re experiencing. We’re also partnering with our joint affiliates across the country and sending out members of our Board, or members of our Healthcare Reform Committee, to provide updates at these joint affiliate meetings right in their jurisdictions. Right in their home states or their home locations to provide live presentations to help them understand what the implications are for their region or their state.
We respond to their questions in those settings to try to help them prepare a little bit more effectively. We also send an entire seminar. We have the annual Day on the Hill, which is sort of our day of lobbying and trying to promote a dialogue with Congressmen and Senators about initiatives and concerns for us in the field of cardiac and pulmonary rehab. So just prior to that, we always have an educational seminar of some sort. This year’s seminar was dedicated to the whole Healthcare Reform agenda, and an R2R Initiative. That was very well received so we’ll continue something similar to that, prior to our annual conference this October down in Charleston.
We’re also going to present a pre-conference with a heavy emphasis on the Healthcare Reform Initiatives and managing these Healthcare Reforms and the programmatic changes that may result from that.
MA: That’s sounds great. I think we are almost out of time, so one last question for you. If you had to change one thing, either legislatively, practice wise or anything about cardiac rehab, what would the one immediate change you’d want it to be?
KT: If I would increase reimbursement. Right now, generally across the country, cardiac rehab is reimbursed roughly, on average, around $100.00 a session. What needs to be understood is that we’re what I would consider a high touch, low tech enterprise. The high touch comes from the human touch, and from reaching out and from working with, coaching, and generally supporting patients. Labor’s expensive and $100.00 an hour or $100.00 a session in no way really covers what it costs to deliver that service.
And I think that in many hospitals, cardiac rehab is the right thing to do and it continues to be a part of the full spectrum of care because it is the right thing to do for patients, but it’s not a money maker. So I think that if it did bring in more revenue, it certainly would help to decrease the deficits that many programs run at, and may raise the profile of the program and perhaps garner them a little bit more support for these efforts, whether that be better physical setups, or more resources.
But certainly, you know, I think that economics still speaks volumes. I think we’re underpaid for really what we do and what patients receive when they come through our programs. So that would be, personally, my number one change.
MA: Agreed, that certainly could make a difference.