Case Model: Cardiac Rehabilitation CEP

Case Model: Cardiac Rehabilitation CEP

Vanessa Valle, CEP |  March 17, 2022
Case Model Cardiac Rehabilitation CEP

My name is Vanessa Valle, and I’m an exercise physiologist at the Cardiac Rehabilitation and Wellness Center at the University of California, San Francisco (UCSF). Our program opened in October 2019 and, just as we were gaining some kind of semblance of momentum, we shut down due to the COVID-19 pandemic. Every policy and procedure that we’d barely finished writing changed, and my role as an exercise physiologist took a different identity.

So I could write about what I do as an exercise physiologist in a cardiac rehab clinic — write exercise prescriptions, monitor patients’ telemetry and blood pressure — but we all know that. I’m going to talk about our roles as listeners and how my role as health care provider during the pandemic challenged me in a different way.

Before the pandemic, our center saw seven patients at a time. It was a fun, social group setting, which was something I loved about cardiac rehab. When COVID-19 started rearing its ugly head, we decided to shut down since many patients became too afraid to come in and, honestly, we as a staff were scared too. We decided to work from home, and I couldn’t fathom what that would look like, especially since IT sure had a hard time configuring my laptop for home use. I was given the task of calling current patients for a weekly check-in and to keep them apprised of our projected reopening.

I became their social outlet. I would call to just check in and would speak to a patient for almost an hour — getting to learn about them as a person and not only as a patient. During those first few weeks, I often felt like I was the only person they regularly got to talk to. And maybe exercise was only 25% of our conversation, but there was a lot of value in that other 75%.

My role changed from writing out exercise prescriptions to figuring out how to get patients to simply move instead of being glued to the TV. I learned so much about a patient’s family, but trying to convince the patient that they need to take care of themselves when they were worried about their aging parents and figuring out how to work from home plus homeschool their kids. I would worry about a patient that lived in an unsafe part of town but only wanted to walk late at night because there were less crowds. It was relatively easy to demonstrate bicep curls to a patient in the center but a whole different challenge to convince that same patient that doing laundry does not count as exercise. And that watching the news is not helping their heart health either.

I had this one wonderful patient who was quite the introvert and always had high blood pressure, which he attributed to “white coat syndrome.” In the first couple weeks of the pandemic, he revealed to me that he was feeling quite lonely. His main social outlet was volunteering at Golden Gate Park helping maintain the gardens. We didn’t focus too much on exercise initially, but I enjoyed talking about his children and Golden Gate Park, and we spent a lot of time helping him figure out Zoom for his medical appointments. Eventually, I was able to get him to use Golden Gate as his playground for exercise. I learned he took up photography in his retirement years and loved to take pictures of wildlife at Stow Lake. So we used his number of laps around Stow as measurements of progress and using the benches and his camera equipment to complete weighted squats. I shared his photography with my coworkers, and we became his friends, giving him a social outlet.

Another patient was eating too many carbs and high-sodium processed foods because he didn’t know how to cook. He relied on his job for free lunches, and his physical activity consisted of walking from building to building. I had to figure out how to motivate a patient who is newly working from home, lacks intrinsic motivation to exercise and has a high-stress, sedentary job. I foolishly asked him if he had a cast iron pan to use as a substitute for weights. He got a good laugh out of that since he did not cook whatsoever! I learned he used to play ice hockey, so I developed an exercise program that included skate jumps and wood chops with the hockey equipment he dug out — plus exercises he can do while his dog chooses to sniff on their walks instead of consistently maintaining the 30-45 minutes of moderate walking intensity that we wish our pups understood.

As we started to slowly reopen, our initial group setting of seven went to a maximum of two patients. Instead of our usual routine of using cardio equipment, we spent more time working one on one and developing an exercise routine patents could complete at home with no exercise equipment. From those months of weekly phone calls, I learned to develop highly individualized exercise programs, spending a lot of time on YouTube finding the perfect exercise video for each patient.

I have a new appreciation — actually a new passion — for teaching leg-strengthening and balance exercises. In my job prior to UCSF, the daily roster consisted of three staff members working with 12 patients. It was almost impossible for one staff member to stay with one deconditioned patient doing weights and balance exercise when you had to help get blood pressures and rates of perceived exertion. Now, I spend more time talking to patients about what exercises they can do at their kitchen countertops, such as heel raises and side kicks. They enjoyed doing some exercise while waiting for water to boil! Initially, I felt guilty taking time away from their NuStep machine and cardio exercises since that was what cardiac rehab centers focus on. However, knowing that our patients would never join a community gym due to COVID-19 surges, we found it more important to develop a routine they could do at home.

So as more mandates are getting lifted and we start to increase our capacity, I’ve learned to not get too focused on taking blood pressures and whipping out exercise prescriptions on the cardio equipment, but instead to think of our patients outside the cardiac rehab center — getting to know them beyond their medical history and to be able to describe them other than what their EF may be. To discover what scares them and what motivates them, and to make exercise more meaningful to them. Instead of calling an exercise by its formal name, like “frontal shoulder raise,” I’ve called it “lift your cat” or “lift your grandchildren.” Does the patient miss travel? I’d call the “overhead press” “luggage in the overhead bin” to make it more meaningful and practical. Do they miss dancing? Patients will appreciate it if you curate YouTube home Zumba videos for them.

Something patients often suggest in our satisfaction surveys is that we have some kind of follow-up months or a year after they complete the program. Unfortunately, I’ve never been at a cardiac rehab that had the staffing to do that. It’s too easy for patients to stop exercising after cardiac rehab since they no longer have the accountability we provide them or access to cardio machines. But if we can spend time creating a very personalized exercise program, particularly more time with a transition-to-graduation plan, we can create a long-lasting motivation that they can find in their everyday life. Maybe they’ll actually buy that cast iron pan.