Policy Issues for Cardiac Rehabilitation Programs
Authors: Burgess Ann Wolbert , Lerner Debra J. , Hartman Carol R. 
Published: October 2007

The definition of nursing practice and the involvement of nurses in the broad scope of the care and rehabilitation of cardiac patients require discussions that support, clarify, and give direction to nursing policy and programs aimed at areas related to heart disease. Nursing research is a key source contributing to public policy, and nurses need to seek out these opportunities for specifying their profession's role in improving the health care system.

With the experience of one year into the study, we believe it takes a structured rehabilitation program to ensure that heart attack patients receive immediate health care essential to recovery to optimum levels of functioning including return to work. We recommend that attention be given to the cognitive component in nursing intervention to aid in neutralizing the intrusive thoughts and feelings and nonadaptive avoidance behaviors, which act as barriers to a nonstressful recovery. The intervention program moves beyond the standard nursing and medical approaches to restoring patients' physical and emotional capabilities to preillness levels by viewing a timely, stable, and clinically uncomplicated return to work as the major indication of recovery from Ml. The intervention draws on the principles and techniques of cardiac nursing and cardiology. The program's unique emphasis on crisis intervention and victim stress response postulates that there is an association between the trauma of an Ml and the existence of cognitive and behavioral barriers to resuming a preillness life‐style. The nursing intervention therefore is conceptualized as a comprehensive method for promoting the manifold aspects of recovery including its clinical, cognitive‐psychosocial, and work‐related components.

The evaluation of nursing's effectiveness in the rehabilitation of cardiac patients must also be considered within the broader arena of issues relating to the delivery and financing of health care. For instance, with this rehabilitation program are we simply adding another stratum of services onto an already burgeoning system of health and medical care? Clearly any new program of this kind must demonstrate its sensitivity to these broader issues presently facing consumers and the providers of these services.

At the outset this cardiac rehabilitation program has certain key advantages. It does not duplicate existing services. The program can be administered on an outpatient basis in a variety of settings, (e.g., ambulatory care settings, clients' homes, the workplace, community service agencies) and requires no new technology or special equipment. Subsequently the cost of training nurses to provide this kind of rehabilitation program can be minimized effectively.

There is, however, a price tag to any new service, and it is not yet clear as to how the costs of a program that focuses on returning cardiac patients to work can or should be distributed. First and foremost, the cardiac rehabilitation program is interested in reducing the incidence of cardiac invalidism, thus increasing the productivity of a potentially large segment of the working population in the United States. Will employers who currently contribute to financing disability insurance for the more than 1.5 million workers annually (National Institute for Occupational Safety and Health, 1980) be willing to bear the costs of a return‐to‐work cardiac rehabilitation program?

The economic costs of disability are costs to the nation as well as to employers. Every worker and employer in the Social Security system pays a tax on wages to support Social Security Disability payments and Medicare, for which the disabled of any age are eligible. Physician services for the disabled are financed largely by general revenue in the federal budget. In addition, many employees and employers are required to pay into a state disability program. And unions usually negotiate for disability benefits, which affects take‐home pay and employer's expenses. Disability is a loss of human capital and it is paid by all of us.

The results of this study also may have important medicolegal implications by helping to clarify the necessity of the so‐called “heart laws.” These laws, which rule out a cardiac's future employment in certain fields, may in fact be unnecessarily restrictive on heart patients' activities while unwillingly forcing some employers to lose prematurely their most useful workers and providing other firms with the incentives they need to fire and hire.

The opportunity for nursing to shape future policy in areas such as employee disability and health benefits and job redesign is an important and pressing challenge raised by the Return to Work program.

Finally, the concern with rehabilitation of the cardiac patient extends beyond any superficial indications of recovery such as assuming success once patients are back on the job. Proof of the effectiveness of the return to work lies in part in restoring patients to an overall state of health and well‐being post‐MI. This means that nursing must effect substantial reductions in the number of productivity days lost due to a patient's poor cardiologic or psychosocial status. It is also anticipated that if the cardiac rehabilitation program is successful in modifying patients' cardiovascular risk status, reducing their stress, and improving their networks of support resources, then the rate of reinfarction is likely to decline in this population. Hence nursing can have an important secondary impact on constraining expenditures at the acute level of hospital care.

A number of crucial questions remain with regard to the Return to Work Cardiac Rehabilitation program.

First, if the nursing intervention is effective in increasing the rate of return to work, is the health care system structured for patients to request this service? For instance, are the third‐party reimbursement mechanisms lacking for nurse clinicians to make home and work setting visits?

Second, if the nursing intervention is effective in cost control, how can this be integrated as an adjunct rehabilitation component?

And third, if the intervention is effective and efficient, would employers wish to request such a rehabilitation module, and how can this program be adapted in a high‐quality manner for use in nonmedical settings?

This project has a highly specific goal of returning patients to work and has been purposefully designed as a adjunct to the standard nursing and medical care available in the hospital sites. By viewing this program as a modular one and involving clinical representatives of the hospital in discussion of its applicability, the program has been seen as an innovative use of available hospital services and professional skills in a manner that is consistent with the current methods and resources of many hospitals.