Professional

Do any of you take BPs or other vitals in phase 3, regularly or just on occasion if someone asks? Or do you do a yearly monitored session? I'm asking because we've run phase 3 very differently over the years. We used to take daily BPs on all phase 3 patients and do a yearly monitored session, and record all their exercises. Now we do none of that, except the RN who runs it (should be an EP in my opinion) keeps paper charts on all of them, updates med lists on paper, sends MD notifications about various issues, and wants clearance to return to exercise for even non cardiac issues (Ortho, etc). We are in the process of updating all of our policies right now and I'm trying to get some things changed. Any thoughts? How do you all run phase 3?

Jason,

We offer a Phase 3 program, and our manager is an NP who is occasionally on the exercise floor. Our staff mix includes EPs, RNs, PTs, and RRTs. We have a lead RN, but she is not really in charge of day to day care.

We take BPs before each exercise session, and if there’s a clinical reason—or if a patient specifically asks—we’ll check BP during or after exercise. We try not to let those extra checks become routine.

We update meds, surgeries, and hospital admissions annually. We don’t send regular communications to providers; we fax or call only when there are symptoms or issues that need attention. When something comes up, we discuss it in rounds and decide what follow‑up is appropriate.

If a patient is out for anything cardiac‑related, or for hospitalizations or surgeries—including hernia, major ortho procedures or cataract surgery—we ask them to bring a clearance note when they return. We don’t request clearance for minor issues like Mohs procedures or simple, non-weight bearing fractures (fingers, etc.), since exercise as usual shouldn't impact healing or safety in those cases.

If a Phase 3 participant hasn’t been in for a week or two, we’ll call to check in and make sure everything is okay.

Since COVID, we’ve relaxed our Phase 3 monitoring. Before the pandemic, we did a once‑monthly paddle check on new or higher‑risk Phase 3 participants, and we also did a once‑monthly BP and HR series (pre‑, peak‑, and post‑exercise all in one day). We documented those vitals along with the patient’s progress.

Peggy Kraus, CEP, CDCES

Cardiopulmonary Rehab

Stony Brook Southampton Hospital

240 Meeting House Lane

Southampton, NY 11968

631-726-8620 office

Thanks for the info, both of you. Seems like there is a wide range of how these programs are run, good to know. I also wanted to ask how much you all charge for phase 3. We charge $75 for two days/week, we don't have the option for three days/week currently.

We charge $200/month for 3x/week or $150/month for 2x/week, with the max limit being 3 months right now due to capacity. We can only accommodate two Phase 3 patients per class (with 8 other Phase 2 patients) so we have to cut them off after 3 months. Everyone wants to stay forever, which is so interesting to me because when I worked in Santa Rosa it was much harder to get patients interested in Phase 3. We charged a lot less, too. I guess people in Marin have more money or something… in Santa Rosa patients always said “I can get a gym membership cheaper than that!” To which I always said, yes - do it! The biggest gift to me is when my patients become independent with their exercise.

We used to exercise phase 2 and 3 together and we had like a dozen phase 2 and even more phase 3 in the gym at the same time. It was a mess. Now they exercise on separate days and the phase 3 program is supposed to be capped at around 6 months but that never took. We have people who have been here for well over 10 years. Where are you located now? I wonder if we could get away with $150/month. I'm in Pleasant Hill, East Bay Northern CA.

Hey Jason,

I wanted to reiterate a similar construct with our Phase III/IV in our department. It is much larger than other Phase III/IVs I’ve seen, we have ours off site in 2 different locations with a few hundred participants between the two. Because of this, we only charge $60 per month and they can use the facility as many days as they like, at any time, unscheduled. We also throw them on a heart monitor once quarterly solely for monitoring purposes. Our patients who came from Phase II seem to like this option as well. This is completely separate from our Phase I (pre covid) and Phase II program that are in the hospital. Phase III/IV are still staffed with RNs and CEPs but there is no difference in responsibility or work duties between the 2 titles, same can be said in Phase II program

Hi Jason,

Currently we are taking BPs in the same way we would do with our Phase 2 patients - pre, peak-exercise, and post. I am trying to get my team to get away from taking the exercise BPs but so far they have not become fully on board with this idea (sometimes it takes a very long time to initiate change in a program that has done things a certain way for a long time!) As Peggy mentioned, I don't see a need to take exercise BP unless there is a clinical reason to do so. The whole point of Phase 3 is to get patients independent with their exercise. Additionally, if someone is in Phase 3 they have been deemed stable enough to do that program so in theory shouldn't be getting wild exercise BP numbers. In my opinion we should not be defaulting to exercise BPs unless there is a clinical reason to do so or the patient asks us.

We have some staff that will go as far as to chart exercise levels and RPEs for the Phase 3 patient which I also think is not helping them in their journey to independence. Ideally we would educate them on how to chart themselves their first few sessions then it is up to them to monitor that. Of course I am always happy to help them, but again - the whole goal is to get them independent.

All of our Phase 3 patients are unmonitored unless there is a clinical reason to put them on a monitor for the day. For example, if they have unusually low heart rate or unusually high heart rate.

This is a really bad idea for several reasons. Ask your Compliance Department how they feel about essentially the same service being billed at two different rates. I'm going to suggest they might not be happy about the idea.

You are on the right track. Stay on it.

Jason,

Sounds like you are offering way too much for Phase 3 participants. We have to get away from thinking they are patients. Phase III/Phase IV programs are essentially independent medically supervised exercise programs for graduates. Just like a Wellness Center. There is no need to have an RN and certainly not an NP supervising these programs. They should be more set up as a come and go independent exercise. Our Phase 3 is an open gym time. We do not schedule rhese participants. They do not have to call and tell us if they are going to not come. It is literally am open gym. They exercise 2x/weekly alongside our pulmonary patients. We require them to be independent with setting up all their equipment, any blood pressure, glucose, oxygen, etc. They are responsible for it all. They have an exercise card but thats only if they want to write down what they are doing. We do have them sign a contract in the beginning that if we need to use a peice of equipment that our Phase II patients take first priorty. It also states that if they have any cardiac related surgery or issue of any kind they inform us, as sometimes that means we get them back as Phase II patients. There shouldn't be a need for any type of documentation at all unless the participant needs to switch over to Phase II due to a new qualifying event. I worked at a hospital for 6 years with a Phase III/Phase IV program that grew out of control. We had BP requirements pre, mid and post. Going from that to being the Director of a 55,000 square foot Medical fitness facility gives you a different perspective. Follow ACSM guidelines. The only requirement for medical clearance should be the absolute or relative contraindications to exercise. When looking at rewriting your P&P I would pull all ACSM guidelines and possibly even Medical Fitness Association to see what the latest recommendations are. I know our hospital based wellness center doesn't even require medical clearance unless a member has been taken out of the facility via EMS.

Thank you for that response! This is more like what I've been envisioning and trying to convince upper management of for a long time now. I will definitely share this response with them. I've already spent the last year+ trying to convince them that nothing states the need for an RN to be present and that we need to get away from updating meds, contacting MDs, getting clearance for everything, etc.

Also, out of curiosity, where do you work?

Never mind, I just read your contact info.

Hi Amy,

Couple of questions, I assume you still keep track of attendance for reporting purposes even though you don't really follow up with them if they don't show? And you probably also keep track of payments, who has paid and who hasn't? Also, you said that you don't keep track of medical issues or why they haven't been coming but also said that you would have to decide if someone needed medical clearance based on contraindications to exercise. Do you just assume they will tell you if they have a cardiac related event since you aren't actively asking them about their medical issues? Our patients have been told they have to report everything and need clearance, which I don't like.

Hi Jason,

We keep track of Phase 3 participants for financial reasons. My Patient Access Specialist takes check and credit card payments. At the beginning of the month, she makes sure to collect all payments. We keep track through a sign in sheet when they arrive. This is just so that we know who is in the building in case we need to evacuate the facility. Buy we don't keep track for reporting purposes. I have felt it is important to keep track of numbers, especially to justify our FTES but my Director is unfortunately not interested in that information and doesn't take in consideration our Phase 3 participants for any type of staffing needs. Even though we do need to have a staff member there during those hours. I don't necessarily agree with that stance, but I pick and choose my battles.

We only take Cardiac and Pulmonary graduates who have completed those programs. If someone doesn't complete the Phase 2 and drops out, we wouldn't allow them to join Phase 3. When a patient does graduate Phase 2, and wants to join Phase 3 we do have them sign a contract. We go over the contract and give them a copy. It clearly states they are responsible for their own vitals, management of their own blood pressure, medication management, insulin/glucose monitoring if diabetic, oxygen set up, etc. This is one of our jobs in Phase 2, to get patients to the point that they don't need us for lifelong exercise. They could decide to go to Planet Fitness or a parks and rec center and we have no control on whether or not to take their vitals. The same should apply for Phase 3. As far as your question regarding contraindications to exercise. Look at the absolute contraindications from ACSM. Most of these would occur in the setting of a hospital or the patient would be hospitalized afterwards, with the exception of severe aortic stenosis. Many of them are in the process of being worked up for a TAVR. Our contract we have them sign requires them to let us know if they've been hospitalized. They will call us if that happens, we will look up why and go from there. In the very few instances this has happened it has been either a cardiac patient that needed another intervention and ended up back in Phase 2 or a pulmonary patient with the same scenario or a pulmonary patient with a significant hospitalization due to underlying pulmonary disorder. In both these scenarios, the patients have received a referral for our services anyway. This may sound harsh, but Phase 3 participants are not patients. Its a medical fitness gym membership. We have to take the clinical hat off and put on the fitness management hat and unfortunately its not coat effective to provide that level of clinical oversight for free or at such a low cost. I hope that helps some. AACVPR is also a great forum to use their dashboard to ask some of these questions.

Hi Amy,

Thanks for the detailed response. I totally agree with taking off the clinical hat and letting them be independent. We say that at my hospital for phase 3 but then the RN updates meds, sends MD notifications, requires clearance for every minor issue, and we make the diabetics check their blood glucose pre and post exercise and treat it if it's below 90. I think we may finally have a manager who is willing to listen and let an EP run the program and stop treating them like patients, we'll see. They sign a bunch of stuff before starting phase 3 also, but that's a good idea to make them responsible for their vitals if they choose to take them. Also, I'm familiar with the contraindications to exercise, I guess I just never thought to apply them to phase 3 clearance but that makes total sense. Right now we require clearance if they stub their toe 😂. I'm hoping new management will finally see the value of EPs and let us run phase 3 the way it should be run. 20 years as a MS CEP and maybe we'll finally get a little credit and not have to be babysat by RNs. TBD.