In the 3rd in a series of blogs on how we might increase awareness and utilization for cardiac rehab, we turn to look at how to help those who have been referred, enrolled and now need to complete the prescribed number of sessions from their health team, i.e. retention/persistence. How do we persist, particularly for those of us that see exercise and nutrition as new behaviors and thus create major obstacles for change. In addition, I will explore the opportunities to make connections and build a community with folks with newly diagnosed heart conditions and how this might be the "secret sauce to success and persistence."
RETENTION/PERSISTENCE: As was discussed in past blogs, the challenge to be referred and to enroll are enormous, but no less challenging is the work to come each time for the prescribed 36 sessions and assure that one takes the steps to create new lasting habits. As Johns Hopkins Cardiologist Dr. Roger Blumenthal states, "Overall, only about half of the people referred to cardiac rehab complete the program, with women far less likely to finish than men."
Many facilities work extremely hard to assure that once a patient has come to their first session/orientation, that they keep coming back, but, as humans, we are a complicated lot... our preference is not to adapt new lifestyles or habits... we liked who we were and how our life was prior to our cardiac event.
Cardiologists and our health team at cardiac rehab know that our preference is to find something easy to do (like take a pill), but, in this case, they also know that cardiac rehab as prescribed is better than a pill-- even if much more challenging to enact.
Facilities try many things to keep people coming back. From "attendance policies" to " information about benefits," many old ideas are being utilized across the country. However, behavioral science shows that there are many ways for us to work at changing our behavior and many of the old ideas represent common myths and mistakes not worth continuing.
Here is one example from behavioral science explaining the challenges of why information is often not effective in helping patients change.
Below I will describe some options that practices might partner with patients to help them decide to stay for all 36 sessions based on work in behavioral economics and behavioral science.
1) Institute nudges in your program. What do I mean by a nudge... “A nudge, as we will use the term, is any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates. Putting fruit at eye level counts as a nudge. Banning junk food does not.” (Thaler & Sunstein 2008, p. 6). So for the purposes of cardiac rehab, how might you create ways for people to keep coming to rehab each session until graduation? Learn more here.
What if around the facility were numerous posters (created by patients for extra points) that depict the research that shows the benefits of completing cardiac rehab? What if videos (less than 1 minute) might be shared at orientation of those patients who have "graduated" and are now positively living life after rehab?
What if at orientation, staff also tested for chronotype and learned that exercise would be best during a certain type of day and would also be working to maximize the facility schedule to accommodate peak exercise and alertness for patients?
What might be nudges you would consider? Small changes that could make a BIG difference in persistence?
2) Healthcare and particularly cardiac rehab persistence can benefit from the role that behavioral economics has made in starting a revolution for behavior change.
What if programs started thinking about the role that cardiac rehab might have in instituting gamification to keep patients motivated about their health in cardiac rehab? What if a partnership was formed with digital health company to outfit patients with ways to earn "points" or "badges" or compete against others who are with similar conditions and or demographics? How might this be seen as a fun reason to go to rehab?
What if rehab programs used a lottery to reward persistence, but not in the typical way but one that leverages how we think? What if we asked everyone who was interested to put in nominal amount of money ($25-50) and if they come each session they would receive that money back and would be given a ticket to enter a lottery that would be held every 3 months for $125 with one winner at the end of the year "celebration" worth $500. If this experiment were to be effective, the $1000 needed annually might save multiple lives and innumerable costs in healthcare.
3) Finally, I think one of the most underutilized aspects of cardiac rehab in a facility is building an intentional community among patients. If you are over 50 and have friends like mine, almost every conversation includes talking about our health and the commonalities we have with different aches and pains.
How might cardiac rehab leverage the ways in which we reach out to find our "tribe" of fellow survivors of cardiac events and work to build a strong community with one another. I have recently worked with the University of Michigan Cardiac Rehab program and am now (at least to our knowledge), one of the first patients co-leading a group orientation where much of the focus is to share our story and build a positive community together.
Here are a few ideas/experiments to try in your facility to assure persistence and a need to come see their new found friends and fellow survivors in class.
What if in order to develop more connected community of cardiac survivors, we take blood pressure in a circle, rather than a straight line and have some conversation starters (on table tents in front of them written down) to help those waiting for blood pressure to talk with each other and develop a new bond?
What if we paired similar age/demographics/event together (with their consent) and worked with them to share their ITP (Individualized Treatment Plans) so they could help each other to improve while building positive relationships with each other?
What if as new members arrived in classes, there were ways to connect the small group of patients who have started in the last week... and then staff worked with them to work toward "graduating" together and getting to know one another?
What if we provided t-shirts (by color) showing the groups are now connected and find ways to partner with local healthy restaurants to give discounts when they come to lunch together?
Working with exercise physiologists' training curriculum may be essential to understand the science that exists for creating community and may be the best thing to have facilities survive the new "home based" digital cardiac rehab craze that may not include this connection with others.
Cognitive Bias(es) these strategies try and overcome or leverage positively include loss aversion, regret aversion, and present-biased preferences. These are all important ways in which we act irrationally or not in our best health interests but by understanding them and building processes and policies in our facilities, we can work to overcome these human tendencies.
Let's keep thinking about new ways (through learning more about behavioral science and behavioral economics) to create new experiments to assure once someone begins rehab, they persist to graduation and beyond.
Action Item: Look up healthcare and behavioral economics and see if you can find and implement a small change that will make a big difference in your cardiac rehab facility! :) How might Cardiac Rehab create a "nudge unit" to find many experiments worthy of trying to increase persistence?
Next time- I will explore ideas and experiments for graduation!