Can phase 2 cardiac rehabilitation be performed in an outpatient setting without a healthcare provider's supervision?

Phase 2 Cardiac Rehabilitation Requires Physician Supervision

No, Phase 2 cardiac rehabilitation cannot be performed in an outpatient setting without a physician's direct supervision or immediate availability. According to current Medicare regulations and professional guidelines, a physician must be in the area of the exercise program and immediately available and accessible in case of an emergency at all times while the exercise program is being conducted. 1

Regulatory Requirements for Physician Supervision

Direct Supervision Mandate

• Services provided by nonphysician personnel must be furnished under the direct supervision of a physician. 1
• The physician does not need to be physically present in the exercise room itself, but cannot be too remote from the exercise area to be considered immediately available and accessible. 1
• Phase 2 cardiac rehabilitation traditionally requires direct physician supervision with the physician immediately available in the exercise area. 2

Setting-Specific Requirements

The supervision requirements vary based on the facility type:

• Hospital-based programs: Physician supervision is presumed to be met when services are performed on hospital premises. 1
• Free-standing outpatient programs (hospital-owned but off-campus): A physician-directed emergency response team must be present and immediately available to respond to emergencies. 1
• Physician-directed clinic or practice: A physician-directed emergency response team must be present and immediately available to respond to emergencies. 1

Common Pitfall: Relying on Code Teams

There is confusion regarding whether reliance on a hospital code team or emergency room physician meets the criteria for direct supervision. Some Office of the Inspector General reports state this does not meet the criteria, while others recognize this practice with the caveat that the supervising physician cannot be geographically remote or involved in an activity that would preclude prompt response. 1

Staffing Requirements Beyond Physician Supervision

Essential Personnel Qualifications

• All professional staff must have successfully completed basic life support (BLS) training. 1
• At least one staff member present must have completed advanced cardiac life support (ACLS) training and met state and hospital medico-legal requirements for defibrillation. 1
• Staff must have experience in exercise training for patients with coronary heart disease. 1

Emergency Preparedness

• Functional emergency resuscitation equipment and supplies for handling cardiovascular emergencies must be immediately available in the exercise area. 1
• Documentation of supervising physician participation and response time is imperative. 1
• Regular practice of emergency procedures should be conducted and documented. 1

Alternative Delivery Models

Home-Based Cardiac Rehabilitation Exception

While traditional Phase 2 requires physician supervision, home-based cardiac rehabilitation (HBCR) represents an alternative model that relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. 3

• HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for cardiac rehabilitation but cannot attend a traditional center-based program. 3
• Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. 3
• Phase 2 cardiac rehabilitation can be delivered through center-based, home-based, telephone-based, or Internet-based programs. 2

Emerging Virtual Models

• Innovative models for delivering cardiac rehabilitation services include in-person sessions, virtual (synchronous) sessions, and remote (asynchronous) sessions. 4
• Hybrid models combining different approaches may be used according to patient needs. 4
• Telerehabilitation has shown preliminary positive outcomes with no adverse events during virtual sessions, though this remains an evolving area. 5

Program Oversight Requirements

Medical Director Responsibilities

• A physician-director must be responsible for the oversight of cardiac rehabilitation program policies and procedures. 1, 4
• The medical director ensures that policies and procedures are consistent with evidence-based guidelines, safety standards, and regulatory standards. 1
• This includes appropriate policies and procedures for the provision of alternative cardiac rehabilitation program services, such as home-based programs. 1

Documentation Requirements

The program must maintain:

• An individualized treatment plan signed by a physician and updated every 30 days. 4
• Documentation of supervising physician participation and response time. 1
• Written program policies demonstrating compliance with structure-based performance measures. 1