Psychosocial services provided by licensed cardiac rehabilitation programs

**Background:** An estimated 805,000 myocardial infarction (MI) events occur annually in the U.S., with 85% of patients surviving to discharge. Depression affects approximately 20% of MI survivors and is a recognized risk factor for poor cardiovascular outcomes—depressed MI patients are 22% more likely to experience all-cause mortality and 13% more likely to experience subsequent cardiovascular events. Comprehensive cardiac rehabilitation (CR) is a Class I recommendation from the American Heart Association (AHA), which includes psychosocial management as a core component. Despite these recommendations, the real-world implementation of psychosocial services in CR programs and barriers to their provision are not well described.

**Methods:** A cross-sectional survey was conducted of all 76 licensed outpatient CR programs in North Carolina, identified from the NC Department of Health and Human Services online directory (accessed September 2018). A unique survey link was emailed to program directors to assess 2018 program offerings. The survey expanded upon prior surveys conducted in 1999 and 2004, with new questions about psychosocial and stress management services, assessment instruments, and barriers. The final instrument contained 60 questions and was administered via Qualtrics between February and June 2019. Descriptive statistics summarized responses overall and stratified by whether programs provided psychosocial services. Standardized differences were computed to detect imbalances between groups (≥10% considered meaningful). Two team members performed thematic analysis of open-ended responses about barriers using a consensus approach, resulting in 16 child codes synthesized into 5 themes.

**Key Results:** Sixty-eight programs (89%) responded. Forty-eight programs (70%) offered psychosocial services, and 94% offered stress management services. At program enrollment, mental health was assessed in 94% of programs, with 92% repeating assessment at discharge. The PHQ-9 was used by 75% of programs. The Ferrans and Powers Quality of Life Index—Cardiac was the most common QoL instrument (72%). Social support was infrequently assessed (16%). Among psychosocial service providers, individual counseling was offered by 59%, counseling referrals by 49%, and educational classes by 29%. On average, 52% of CR participants utilized psychosocial services. Stress management services were provided by nurses (44%), exercise physiologists (19%), and psychiatrists/psychologists (19%). The majority of programs never billed insurance for psychosocial services (73%) or stress management services (81%). The top barriers identified by program directors were lack of internal resources related to organizational expense (47%), staffing (42%), and time (33%). Patient beliefs were cited by 45% of programs as a barrier, including low interest (25%) and patient reticence (20%).

**Clinical Implications:** This statewide study demonstrates that while NC CR programs are highly compliant with psychosocial assessment recommendations—representing a marked increase from the 29-68% assessment rates observed globally between 1995 and 2010—there remains a substantial gap between screening and service provision. The finding that 73% of programs do not directly bill for psychosocial services reflects Medicare's focus on medically supervised exercise training (2-3 sessions/week for 12-18 weeks) without additional reimbursement for counseling. Financial barriers are not unique to the U.S. and have been reported in other countries. The identification of patient beliefs as a major barrier (45% of programs) underscores the need for interventions to reduce mental health stigma and improve patient awareness of the connection between mental and physical health. Given that only 30-50% of eligible patients attend even one CR session, efforts to increase overall CR participation are needed to maximize the benefit of psychosocial services. Future research should investigate alternative payment models, implementation strategies for programs not currently providing psychosocial services, and the mental health status of CR-eligible patients who do not attend any sessions.