AACVPR/AHA Scientific Statement

Medical Director Responsibilities for Outpatient Cardiac

Rehabilitation/Secondary Prevention Programs: 2012 Update
A Statement for Health Care Professionals From the American Association
for Cardiovascular and Pulmonary Rehabilitation and the American
Heart Association
Marjorie King, MD; Vera Bittner, MD, MSPH; Richard Josephson, MD; Karen Lui, RN, MS;
Randal J. Thomas, MD, MS; Mark A. Williams, PhD

Abstract—Medical directors of cardiac rehabilitation/secondary prevention (CR/SP) programs are responsible for the safe
and effective delivery of high-quality CR/SP services to eligible patients. Yet, the training and resources for CR/SP
medical directors are limited. As a result, there appears to be considerable variability throughout CR/SP programs in the
United States in the roles, responsibilities, and engagement of CR/SP medical directors. Since the publication of the
2005 scientific statement from the American Heart Association and American Association of Cardiovascular and
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Pulmonary Rehabilitation regarding medical director responsibilities for outpatient CR/SP programs, significant changes
have occurred. This statement updates the responsibilities of CR/SP medical directors, in view of changes in federal
legislation and regulations and changes in health care delivery and clinical practice that impact the roles and
responsibilities of CR/SP medical directors. (Circulation. 2012;126:00-00.)
Key Words: AHA Scientific Statements 䡲 cardiac rehabilitation 䡲 exercise training 䡲 medical director

O utpatient cardiac rehabilitation/secondary prevention

(CR/SP) programs are recognized as a key component
of the management of patients with a variety of cardiovascu-
lar conditions, including stable angina, recent myocardial
infarction or acute coronary syndrome, or heart failure, or
following coronary revascularization procedures, valve sur-
gery, or cardiac transplantation. In addition to improving
adherence to medication regimens and lifestyle recommen-
dations, enhancing quality of life and psychosocial well-
being, and increasing functional capacity, recent research has
shown that participation in CR/SP programs reduces 5-year
mortality by 25% to 46% and recurrent nonfatal myocardial
infarction by 31%.1–3 Similar to many other therapeutic
interventions, there is evidence that those who participate in
more CR/SP sessions obtain greater benefits.1,3 As a result,
referral to CR/SP programs is currently included in numerous
clinical guidelines, with a high level of evidence and strength
of recommendation.4 –11 In addition, referral to CR/SP pro-
grams is incorporated into performance measure sets for
myocardial infarction and chronic oronary artery disease.12,13

From Helen Hayes Hospital, West Haverstraw, New York, and Columbia University, New York, New York (M.K.); Division of Cardiovascular
Disease, Department of Medicine, University of Alabama at Birmingham (V.B.); Harrington Heart and Vascular Institute, University Hospitals Case
Medical Center, and Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio (R.J.); Governmental
Representation with Quality, LLC, Vienna, Virginia (K.L.); Cardiovascular Health Clinic, Division of Cardiovascular Diseases, Department of Internal
Medicine, Mayo Clinic, Rochester, Minnesota (R.J.T.); and Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
(M.A.W.).
This statement was approved by the American Association for Cardiovascular and Pulmonary Rehabilitation in May 2012, and the American Heart
Association Science Advisory and Coordinating Committee in June 2012.
The American Heart Association requests that this document be cited as follows: King M, Bittner V, Josephson R, Lui K, Thomas RJ, Williams MA.
Medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: 2012 update: a statement for health care
professionals from the American Association for Cardiovascular and Pulmonary Rehabilitation and the American Heart Association. Circulation.
2012;126:000 – 000.
This article has been copublished in the Journal of Cardiopulmonary Rehabilitation and Prevention.
Copies: This document is available on the World Wide Web sites of the American Association for Cardiovascular and Pulmonary Rehabilitation
(www.aacvpr/JCRP) and the American Heart Association (my.americanheart.org). A copy of the document is available at http://my.americanheart.org/
statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843–216-2533 or e-mail
kelle.ramsay@wolterskluwer.com.
Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines
development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-
Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.
Correspondence: Marjorie L. King, MD, Helen Hayes Hospital, West Haverstraw, NY 10993 (kingm@helenhayeshosp.org).
© 2012 by the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e318277728c

1
 2 Circulation November 20, 2012
Legislation passed by the US Congress in 2008 stipulated
that a medical director is required for the operation of CR/SP
programs, and that CR/SP is defined as “a physician super-
vised program that furnishes physician prescribed exercise,
cardiac risk factor modification, psychosocial assessment,
and outcomes assessment” (italics added).14 As a result of this
legislation and changes in the science and practice of CR/SP,
the American Association of Cardiovascular and Pulmonary
Rehabilitation (AACVPR) and the American Heart Associa-
tion (AHA) deemed it important and necessary to update the
2005 AACVPR/AHA statement on the roles and responsibil-
ities of CR/SP medical directors.15
The purpose of this document is to provide an update
regarding legislative, regulatory, programmatic, and clinical
issues that impact CR/SP medical directors. It is not meant to
repeat information regarding CR programming, which can be
found in guidelines and statements elsewhere.16 –19 Rather, it
concentrates on the unique roles and responsibilities of the
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CR/SP medical director. This document describes relevant
regulatory and legislative requirements, explains the clinical
rationale behind the involvement of medical directors in
CR/SP programs, includes information that helps physicians
develop the specific skill sets needed to be effective medical
directors, and provides resources that can be used by the
medical director to promote evidence-based and cost-
effective CR/SP services. Together, these should result in
good patient outcomes, patient satisfaction, and employee
satisfaction.
Medicare Regulations
Section 144 of the Public Law 110 –275 titled, “Medicare
Improvements for Patients and Providers Act of 2008,”14
established a new section of the Medicare statute for coverage
and payment of cardiac rehabilitation, intensive cardiac rehabil-
itation, and pulmonary rehabilitation services. On the basis of
this specific legislative language, the Centers for Medicare &
Medicaid Services (CMS) developed a revised Medicare provi-
sion for cardiac rehabilitation.20 Within the Medicare provision
are requirements that address qualifications for medical direction
and physician supervision, as well as roles and responsibilities of
the medical director related to individual treatment plans and
outcomes assessment.
Regulatory Requirements for the Physician
Responsible for the CR/SP Program
The CMS defines a CR/SP medical director as a physician
who oversees a CR/SP program at a particular site. The
standards for this physician are the following:
● expertise in the management of individuals with cardiac
pathophysiology;
● cardiopulmonary training in basic life support or advanced
cardiac life support; and
● licensure to practice medicine in a state where the CR/SP
program is offered.
A CR/SP medical director need not be a cardiologist, but
he or she needs to be a licensed physician, whose scope of
practice includes the treatment of cardiovascular disease
(CVD). The term physician, as defined by CMS, means a
doctor of medicine or osteopathy.20
A medical director is responsible for directing the progress
of individuals in the program, in consultation with the CR/SP
staff. Although the medical director is not required to scru-
tinize the medical record of every patient, he or she should be
aware of patients’ conditions and progress throughout their
time in the program. This is most effectively done in close
collaboration with the multidisciplinary team.
Outcomes Assessment
The CMS regulations state that outcomes are “. . . measured
by the physician.”20 The process of outcomes assessment is a
formal evaluation of the progress that a given patient achieves
as a result of an individualized CR/SP treatment plan. CMS
allows each program to determine which outcomes are more
appropriately measured at the beginning and the end of the
program and which outcomes would be more helpful to
measure as the patient progresses through the program. This
outcomes assessment is done in conjunction with the CR
staff, with the expectation that the medical director is in-
volved in this process.
Individualized Treatment Plan
It is important that the medical director and all CR/SP staff
are familiar with an individual patient treatment plan; how-
ever, it is the responsibility of a physician to review, modify
if needed, and sign the initial and subsequent individualized
treatment plans (ITPs).20 This physician can be the medical
director or one of the physicians involved in the patient’s
cardiovascular care or secondary prevention. Specific com-
ponents of the ITP are discussed later in this statement.
Regulatory Requirements for Medical Supervision
The CMS requirement of direct physician supervision for any
therapeutic outpatient hospital service also applies to CR/SP
programs.20 Currently, the CMS requires the immediate
physical availability of the supervising physician and ex-
cludes remote access, such as by telephone or by other modes
of communication, other than in person. CMS defines a
supervising physician as one who is immediately available
and accessible for medical consultations and medical emer-
gencies at all times when the CR/SP program is in opera-
tion.20 CMS does not require that the medical director be the
supervising physician; however, the medical director is re-
sponsible for ensuring that regulatory requirements for med-
ical supervision of the CR/SP program are met.
The regulatory requirements for physicians providing di-
rect physician supervision during exercise sessions are ex-
actly the same as those listed earlier for the medical director.
Although advanced practice nurses and physician assistants
are increasingly assuming patient care roles that were previ-
ously the sole province and responsibility of physicians,
current CMS guidelines do not permit such practitioners to
fulfill the role of the supervising physician in CR/SP
programs.
Regulatory Summary
From a regulatory perspective, the medical director is respon-
sible for the following:
 King et al Medical Director Responsibilities for Outpatient Cardiac Rehabilitation
● ensuring that patients enrolled in the program meet quali-
fying diagnoses/medical conditions;
● providing oversight of patient progress and outcomes
assessment;
● assuring appropriate supervised exercise for each patient,
in consultation with the CR/SP staff;
● supervising the quality of care provided by the multidisci-
plinary CR/SP staff; and
● ensuring that regulatory requirements for medical supervi-
sion of the CR/SP program are met.
Qualifications and Skills for an Effective
CR/SP Medical Director
Minimum qualifications of CR/SP medical directors as de-
fined in current legislative and regulatory language are
outlined earlier. In addition, medical directors should be
appropriately credentialed within their institutions and should
be contracted in such a way that they have the time to devote
to the responsibilities that come with their role as a director.
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Medical directors must also make a commitment to staying
abreast of new regulatory developments21,22 and participating
in continuing medical education related to CVD in general
and aspects of CVD prevention and rehabilitation in partic-
ular. Basic skills in data collection and analysis, outcomes
assessment, and quality improvement strategies are highly
desirable to facilitate communication with others in the health
care organizations focused on these tasks.
Preventive cardiology encompasses many content areas, as
described in detail in the American College of Cardiology,
the AHA, and the American College of Physician compe-
tency statements.23,24 Although these reports were published
to guide subspecialty training in CVD, and cardiovascular
subspecialty training is not a prerequisite for directing a
CR/SP program, these statements can serve as a roadmap for
continuing medical education of CR/SP medical directors.
Specifically, the medical director should acquire and maintain
basic knowledge about the core competencies related to
CVD, secondary prevention, data analysis, and program
oversight outlined in Table 1.
Medical directors must possess sufficient leadership and
communication skills, not only to lead a multidisciplinary
team of health care professionals directly involved in provi-
sion of CR/SP services but also to communicate with a
patient’s other healthcare providers and with administrative
leadership. In an era of increasing accountability for health
care outcomes and value-based purchasing, medical directors
of CR/SP programs are uniquely positioned to help guide
their health care organizations as they strive to become
institutions that can demonstrate that they deliver high-
quality preventive care for patients with CVD, which is
cost-effective and improves patient outcomes.
Responsibilities Related to Program Development
and Operations
Responsibilities of the CR/SP program medical director
include direct participation in the processes of program
development in the case of new programs and of subsequent
program oversight and in the evaluation of effectiveness. The
medical director should ensure that the policies and proce-
3
Table 1. Core Competencies for Cardiac Rehabilitation/
Secondary Prevention Medical Directors
Expertise in the management of individuals with cardiac pathophysiology
Training in basic life support or advanced cardiac life support
Licensure to practice medicine in the state where the CR/SP program is
offered
Credentialed by the hospital or facility in which the CR/SP program is
offered
Team leadership skills
Knowledge about the following:
Cardiac rehabilitation and secondary prevention programs
Cardiovascular biology
Clinical epidemiology and disease management
Cardiovascular pharmacology
Behavioral and psychosocial aspects of cardiovascular disease
Cardiovascular risk assessment and risk factor management
Exercise physiology and exercise training
Biostatistics and interpretation of data derived from clinical trials and
outcomes research
Understanding the following areas related to their institution and community:
Quality improvement systems
Local, state, and federal regulations related to CR/SP
Other existing secondary prevention and disease management programs
Demographics of patients eligible for CR/SP, including barriers to
participation
Budgetary processes
CR/SP indicates cardiac rehabilitation and secondary prevention.
dures are consistent with evidence-based guidelines, comply
with regulatory and certification standards, and recognize
regulations for, and issues pertaining to, reimbursement for
services.14,16,19,20,25 In addition, medical directors should pro-
mote policies and practices aimed at improving CR/SP access
and delivery to all patients who could benefit, including
traditionally underserved patient populations,26 –32 stress the
interdisciplinary care of CR/SP,18,25 and facilitate clear,
concise program documentation that maximizes communica-
tion among those responsible for the health care of a patient.16
Specific responsibilities of a CR/SP medical director, related
to program development and operations, are detailed in Table
2 and are explained in more detail later.
Tracking and Ensuring Program Effectiveness
The CR/SP medical director is responsible for overseeing the
CR/SP program’s overall effectiveness in delivering high-
quality CR/SP services to all eligible patients within the
program service area. To carry out these responsibilities,
the CR/SP medical director must oversee activities that utilize
the following concepts and practices:
● Enlist the support of local physician and nonphysician
leadership to support the role of CR/SP services in provid-
ing high-quality care to patients with CVD. Efforts to
bridge the gap in the delivery of high-quality CR/SP
services will be most successful when local leaders include
CR/SP as a priority area of focus for local quality
improvement.21,26
 4 Circulation November 20, 2012

Table 2. Responsibilities of Cardiac Rehabilitation/Secondary Prevention Medical Directors*

Supervise qualified, multidisciplinary CR/SP staff to deliver high-quality care to eligible patients
Ensure the CR/SP team meets and maintains core competencies
Promote continuing education for CR/SP team
Ensure that policies and procedures are consistent with evidence-based practice guidelines and regulatory and certification standards
Ensure that appropriate emergency response is available
Provide medical advice to CR/SP team for specific patients as needed
Demonstrate that the CR/SP program meets standards of care
Ensure referral and enrollment of appropriate patients
Work with the CR/SP team and facility administrators to identify eligible patients within the program’s service area
Stress the benefits of CR/SP to health care professionals, patients, and families
Ensure that policies and systems promote referral of all appropriate patients, including ethnic minorities, the elderly, and women
Promote automatic or facilitated referral systems if needed
Oversee implementation or continued use of a database that allows the CR/SP program to assess the percent of eligible patients who actually enroll and complete the
prescribed course of CR/SP
Oversight of the ITP
Ensure that policies and procedures are in place to formulate, implement, and modify a clear, concise, and logically organized ITP
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Facilitate development of a program record that shows a clear, concise, logical, and organized ITP
Work with staff to ensure that the ITP can match the needs of individual patients
Help CR/SP programs use risk stratification to provide patient-specific strategies for risk reduction, modify exercise protocols, and determine the level of medical supervision and
monitoring needed for individual patients
Ensure appropriate exercise prescription, in conjunction with CR/SP staff
Ensure that systems are in place for individualized education, counseling, and behavioral intervention about cardiac risk factor modification
Ensure that the ITP is reviewed and signed periodically by a physician
Promote communication with referring physicians about individual patient outcomes and progress toward goals
Direct progress of individual patients
Be aware of the patient’s conditions and progress through the program
Help CR/SP staff solve problems and communicate with referring health care practitioners about deviations from individual patient goal attainment
Educate patients and health care professionals
Participate in patient education sessions when appropriate
Educate CR/SP staff about emerging concepts in treatment and diagnosis of cardiovascular disease
Facilitate education of junior health care professionals about CR/SP
Ensure outcomes assessment
Promote utilization of information management and data collection systems that assist in outcomes assessment and quality improvement practices
Work with the CR/SP team to ensure appropriate outcomes assessment for individual patients
Ensure that the program is successful in the attainment of meaningful patient and program outcomes
Ensure collection of program outcomes and analysis of data
Work with the CR/SP team to apply quality improvement strategies for program improvement
CR/SP indicates cardiac rehabilitation and secondary prevention; ITP, Individualized Treatment Plan.
*From American Association of Cardiovascular and Pulmonary Rehabilitation19 and Hamm et al.25

● Identify all eligible CR patients within the service area of
the CR/SP program. Unless eligible patients are properly
identified, the medical director and staff of a CR/SP
program will have difficulty improving the impact of their
services. Effective identification of eligible patients re-
quires an active, collaborative approach with local hospi-
tals and practices, in which there is recognition of joint
accountability for identifying and treating all patients in
need of CR/SP services.21,26 This approach is essential to
extend the reach of CR/SP services to all eligible patients,
but it is especially important for improving the delivery of
care to those patient subgroups who are least likely to
receive CR/SP services, including women, the elderly, and
individuals from racial or ethnic minority groups.27–31 To
improve utilization of CR/SP services, hospitals, outpatient
practices, and CR/SP programs will need to use innovative
strategies and delivery models, and health care systems will
need to implement policies and strategies that reduce
barriers.21,32,33
● Deliver high-quality CR/SP services to eligible patients.
The delivery of high-quality CR/SP services by CR/SP
professionals to eligible patients requires that CR/SP pro-
grams incorporate a number of critical concepts, core
components, and key competencies.16,25 Program certifica-
tion is available for programs that meet quality
standards.21,34
 King et al Medical Director Responsibilities for Outpatient Cardiac Rehabilitation
● Apply quality improvement strategies through a continuous
improvement cycle that includes the following steps:
䡩 agree on targets to measure that will demonstrate high-
quality CR/SP care;
䡩 assess current performance and gaps in performance
relevant to these targets; and
䡩 adjust the CR/SP program policies and processes to
improve performance.
● Utilize data collection systems that assist in the implemen-
tation and assessment of quality improvement practices in
the CR/SP program.35 Medical directors should consider
utilizing a database to track composite program outcomes,
including those related to enrollment in CR/SP after refer-
ral, completion of the prescribed course of CR/SP, im-
provements in lifestyle habits and functional capacity,
control of CVD risk factors, use of preventive medications,
and frequency of recurrent cardiovascular events, hospital-
izations, or death rates.36
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Issues Related to Patient Referral
Effective referral to and enrollment in CR/SP programs by
eligible patients can be greatly influenced by the medical
director’s endorsement and promotion of patient participation
in CR/SP within the medical community, and by encouraging
the use of effective tools such as automated or facilitated
CR/SP referral systems.32,33
Medical directors must work with the CR/SP team and
facility administrators to develop policies related to the
referral of all medically appropriate patients, both during
hospitalization and in the outpatient setting. The medical
director’s emphasis on the value of CR/SP services for all
potential candidates, as an extension of the referring physi-
cian’s care, will enhance the referral process, while under-
scoring the continued involvement of the referring health care
practitioner.
Inclusion and Exclusion Criteria
Currently, CMS regulations20 provide CR/SP coverage for the
following diagnoses:
● acute myocardial infarction within the preceding 12
months;
● coronary artery bypass surgery;
● stable angina pectoris;
● heart valve repair or replacement;
● percutaneous transluminal coronary angioplasty or coro-
nary stenting; and
● heart or heart-lung transplant.
However, covered diagnoses vary among payers, with
many recognizing the growing scientific evidence of the
benefits of cardiac rehabilitation in patients with heart failure,
including those with ventricular assist devices, and less
frequently, in patients with intermittent claudication due to
peripheral artery disease.10,11 When policies suggest that a
particular diagnosis will not be covered, most carriers have an
appeal process that may result in coverage if appropriate
documentation, showing medical necessity of the CR/SP
services, is provided. In addition, while some patients may be
restricted to participate in only certain aspects of the exercise
5
program because of musculoskeletal or neurological issues or
relative contraindications to exercise,37 enrollment should
still be considered so that these patients can benefit from the
other components of the program. Approaches to such pa-
tients should be individualized and may require guidance by
the medical director.
Tracking and Monitoring CR/SP Program Referral
To help measure and subsequently improve the gap in the
delivery of CR/SP services to eligible patients,38,39 perfor-
mance measures have been developed, published, and en-
dorsed and are being implemented throughout the United
States.40 – 42 Hospitals and outpatient practices that provide
care for patients with CVD are expected to report on their
adherence to these performance measures. Outpatient prac-
tices will be subject to CMS chart-review audits for their
adherence to CR/SP referral performance measures, begin-
ning in 2014.43 The CMS has stated that the referral measure
pertaining to the hospital inpatient setting would also be
beneficial in the future from a continuity-of-care perspec-
tive.44 Medical directors for CR/SP programs can serve as a
resource to hospitals and outpatient practices as they incor-
porate CR/SP referral performance measures42 into the track-
ing and monitoring of their processes of care using national
databases. These databases include the following:
● Inpatient database systems. The American College of
Cardiology Foundation and AHA have combined efforts in
the ACTION Registry—Get With The Guidelines45 regis-
try—to help with point-of-care prompts and automated
system that help inpatient health care teams refer patients to
CR/SP programs and help hospitals track the referral rates
of eligible patients to such programs. The Society for
Thoracic Surgery database also collects information on
surgical patients who have undergone coronary artery
bypass surgery, heart valve surgery, and heart transplanta-
tion, making them eligible for CR/SP services.46
● Outpatient database systems. The Guideline Advantage, a
collaboration by the American Cancer Society, the Amer-
ican Diabetes Association, and the AHA/American Stroke
Association47 and the American College of Cardiology
Foundation’s PINNACLE48 and Cath-PCI49 registries, part
of the American College of Cardiology Foundation’s na-
tional cardiovascular data registry, help outpatient practices
track the referral of eligible patients to CR/SP programs.
The PINNACLE registry has been designated by CMS to
qualify as part of the physician quality reporting system,
which currently rewards practices financially for submit-
ting quality-of-care data for their practice to CMS.
Facilitating Individualized Patient-Centered Care
The medical director is defined as a physician that oversees or
supervises the cardiac rehabilitation program at a particular
site.20(p62004兲 The AHA guidelines for secondary prevention
and those of the AACVPR provide a useful framework for
evaluation, goal development, outcomes tracking, and emer-
gency management.4,16,19 This information is also useful to
risk stratify patients for the following conditions: (1) disease
progression and the likelihood of future cardiac events and
(2) adverse cardiac events during exercise training. Medical
 6 Circulation November 20, 2012
directors should help CR/SP program staff utilize risk strat-
ification to
● individualize exercise-training protocols;
● determine the level of monitoring needed during exercise
training;
● guide individualized secondary prevention education,
counseling, and treatment goals; and
● advise out-of-program exercise activities.
Medical director participation in staff and patient education
sessions can be invaluable to reinforce basic principles of
secondary prevention and provide information about recent
developments in cardiovascular treatments and diagnostic
procedures, so that the CR/SP team can be more effective in
individualizing risk stratification and treatment plans. Evalu-
ation and goal development should address each of the core
components of secondary prevention relevant to a particular
patient, as previously described by the AHA and the
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AACVPR.16
Individualized Treatment Plan
The medical director should ensure that policies and proce-
dures are in place to formulate and implement an ITP for each
participant, which is used to set goals with the participant,
track progress, and communicate with other health care
professionals. Successful implementation of an ITP requires
timely flow of information from the program to other health
care practitioners involved in the patient care and from these
health care practitioners to the program. The medical director
should help the CR/SP program staff develop systems and
processes to facilitate this information flow.
The ITP is described in CMS regulation20 as a written plan
tailored to each individual patient that includes all of the
following:
● a description of the individual’s diagnosis;
● the type, amount, frequency, and duration of the items and
services furnished under the plan; and
● the goals set for the individual under the plan.
Note that the ITP must be reviewed and approved by a
physician, typically the referring physician or medical direc-
tor, upon patient initiation of CR/SP, and at least every 30
days thereafter, until completion of early outpatient (phase II)
CR/SP.20 To be clinically useful, the ITP should reflect the
patient’s current status and guide the development and
implementation of the following:
● a patient-specific treatment plan that prioritizes goals and
outlines intervention strategies for exercise training and
CVD risk reduction and
● a followup plan that reflects progress toward goals and
guides long-term secondary prevention strategies, includ-
ing strategies to improve medication compliance.
Ideally, goals and progress are measured in a quantitative
fashion, and they differentiate between short-term goals that
may be reasonably accomplished during CR/SP enrollment
and long-term goals that require additional time and are
attainable by the patient with continued lifestyle modification
and medical management. Findings and recommendations
resulting from the initial evaluation should be communicated
to both patients and their health care providers in order to
develop strategies to support long-term goals. Patient out-
comes that reflect progress toward goals should be docu-
mented and tracked to identify specific areas that require
further intervention and monitoring during future outpatient
encounters.35,41
CMS regulations require that an assessment be performed
at a minimum at the beginning and the end of the CR/SP
program, and it should include “objective clinical measures of
exercise performance and self-reported measures of exertion
and behavior,” as well as other data on goals identified in the
ITP.20(p62004) At completion of early outpatient CR/SP, a
summary of patient progress toward goals should be commu-
nicated to the patient and his or her referring and other
appropriate physicians and health care providers, to facilitate
ongoing, long-term CR/SP therapies.
The Role of the CR/SP Medical Director in
Professional Education
Cardiac rehabilitation and secondary prevention medical
directors and their programs are uniquely positioned to
educate and train students and health care professionals from
many disciplines, involved in cardiac rehabilitation and/or
secondary prevention of CVDs. This education can range
from seminars or lectures, to informal observational activi-
ties, to structured rotations in the CR/SP program as part of a
formal education or training program. Cardiology fellowship
training requirements, for example, include exposure to and
training in CR/SP.24,50 Similarly, many undergraduate and
graduate programs in exercise physiology and other disci-
plines require hands-on training in a clinical setting. If such
training opportunities are made available in a CR/SP pro-
gram, the CR/SP medical directors should be actively in-
volved in developing goals and objectives for these rotations
in collaboration with the trainees’ advisor(s) and consistent
with relevant graduation requirements. The CR/SP medical
director must ensure that trainees are appropriately creden-
tialed at the institution, trained in protection of personal
health information, and meet other regulatory requirements.
Summary and Conclusions
Since publication of the first AHA/AACVPR statement
regarding the roles and responsibilities of the CR/SP medical
director in 2005,15 changes in regulations, health care deliv-
ery, and clinical practice have made the role of the medical
director even more critical for delivery of quality CR/SP
programming. Strong participation by a knowledgeable
CR/SP medical director, working collaboratively with the
CR/SP team and referring health care practitioners, is essen-
tial to ensure that treatment is individualized, communication
is optimized, and outcomes are tracked to improve individual
patient outcomes and overall program effectiveness. More-
over, because underutilization of CR/SP remains a problem,
particularly for those who can benefit the most, CR/SP
medical directors must work within their communities to
develop systems and programs to reach these patients. The
 King et al Medical Director Responsibilities for Outpatient Cardiac Rehabilitation
role of the CR/SP medical director as a team leader remains
a core concept, but it is even more critical to understand the
role within changing health care delivery models, the increas-
ing emphasis on patient-centered outcomes, and the need to
deliver cost-effective care. Leading the CR team and medical
community toward effective changes and continuous im-
provement in CR/SP program delivery and patient outcomes
is arguably one of the most important roles for CR/SP
medical directors, now and in the coming years.
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Disclosures
Appendix 1. AACVPR/AHA Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs:
2012 Update, Author Relationships With Industry*
Writing Research Other Speakers Expert Ownership Consultant/Advisory
Group Member Employment Grant Research Support Bureau/Honoraria Witness Interest Board Other
Marjorie King Helen Hayes Hospital, None None None None None None None
Columbia University
Vera Bittner University of Alabama None None None None None None None
at Birmingham
Richard University Hospitals Case NHLBI†; NIA†; None None None None None None
Josephson Medical Center, Case AHRQ†
Western Reserve University
School of Medicine
Karen Lui Governmental None None None None None None None
Representation With Quality
Randal J. Thomas Mayo Clinic None None None None None None None
Mark A. Williams Creighton University School Dept of HHS†; None None None None None None
of Medicine NIA†; NIH†
*This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all writing group members are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share
of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the
preceding definition.
†Modest.
 King et al Medical Director Responsibilities for Outpatient Cardiac Rehabilitation 9

Appendix 2. AACVPR/AHA Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs:
2012 Update, Reviewer Relationships With Industry*
Other Speakers
Research Research Bureau/ Expert Ownership
Reviewer Employment Grant Support Honoraria Witness Interest Consultant/Advisory Board Other
Philip Ades University of Vermont None None None None None None None
Gary J. Balady Boston Medical Center None None None None None None None
Nanette Wenger Emory University School None None None None None Eli Lilly Raloxifene Advisory Committee†; None
of Medicine Heart Disease in Women, MED-ED,
Pfizer†; Cardiology/Lipidology Advisory
Board, Merck† Cardiology Consultant,
Bristol Myers Squibb†; Ranolazine
Advisory Board, Women’s Advisory
Board, CV Therapeutics†;
SanofiAventis†; Kos Pharmaceuticals
W.A.T.C.H. Program†; NitroMed
Heart Failure Advisory Board†;
LCIC Executive Committee,
Schering-Plough†; Coreg post-MI
Advisory Panel, GlaxoSmithKline†
Downloaded from http://circ.ahajournals.org/ by guest on June 28, 2017

Ross Arena University of New Mexico None None None None None None None
Gerene Bauldoff Ohio State University None None None None None None None
Eileen Collins Edward Hines Jr. VA Hospital VA‡; NIH‡ (not None None None None None None
and University of related to paper)
Illinois at Chicago
Carl Lavie John Ochsner Heart and None None None None None None None
Vascular Institute
*This table represents the relationships of reviewer that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “Significant” if (a) the person receives $10 000 or more
during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
†Modest.
‡Significant.
 Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary
Prevention Programs: 2012 Update: A Statement for Health Care Professionals From the
American Association for Cardiovascular and Pulmonary Rehabilitation and the
American Heart Association
Marjorie King, Vera Bittner, Richard Josephson, Karen Lui, Randal J. Thomas and Mark A.
Williams
Downloaded from http://circ.ahajournals.org/ by guest on June 28, 2017

Circulation. published online October 22, 2012;

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