The current COVID-19 crisis has put a lot of pressure on cardiac rehabilitation programs in the past few weeks. Initially, this pressure was caused by the prioritization of staff to be able to handle surge volumes, cancellation of elective procedures and the halting of brick and mortar cardiac rehab operations due to concerns over the safety of patients. These changes meant that facility-based cardiac rehab participation effectively went to zero.

The effects were widespread as patients could not get access to the lifesaving benefits of cardiac rehab - a situation that might have adverse implications for their long-term health. From an economic perspective, several staff were switched to part time, transferred to other departments, or were furloughed until operations could begin again. Such moves might have long-lasting effects regarding the sustainability of facility-based cardiac rehab.

Recent weeks have had more positive news. As the curve flattens nationally, stay at home orders are lifted and elective procedures are gradually reopened, center-based rehab facilities now have the chance to re-open and serve their patients.

The reopening of rehab, poses several questions about staying effective without putting patients at risk - How can staff and patients protect themselves from infection? What is the ideal class size? What types of patients would be considered an appropriate population to come on site? How does one implement social distancing measures such as a 6 feet distance? Is it safe to use shared machines? What about locker rooms? Compounding this problem is the uncertainty about how long such measures will need to be undertaken and whether the relaxation of shelter at home orders will lead to future waves of COVID-19 thus putting us in a situation of two steps forward, one step backward.

In our conversations with rehab facilities across the country, one thing has become abundantly clear - one cannot go back to business as usual, instead we are in a"new normal". Rather than be a cause of concern, we have found that this new normal has created opportunities for cardiac rehab to evolve further through alternative, technology-driven models of delivery to stay resilient.

During COVID-19, we have had the privilege of helping our provider partners leverage technology and serve several hundred patients in at-home settings. As we have gone through those rollouts, we have identified four distinct lessons the we felt could be used:

1) The power of personal relationships- one of the most important therapeutic effects in cardiac rehab is the power of human to human interaction and how it can be used as an agent of positive change for patients. One such relationship is between the patient and a cardiac rehab staff member. The epiphany we had was that this relationship need not be restricted to the four walls of a rehab facility. In our rollouts, staff used technology in the form of phone calls and secure chats to reach out to patients. During these interactions, by acting asa friend, philosopher, and guide, cardiac rehab staff members could help the patient think through a plan that maximizes success even though they could not see them in person. Facility-based rehab is known for the benefits of community support. However, what we heard again and again was that rehab staff really appreciated the one-on-one attention that they were able to give their patients which they felt was neglected in a class setting. We feel that this habit of calling patients to provide personalized should continue.

2) The power of anytime-anywhere help - By using technology such as chats, rehab staff could continue to be a valuable resource for their patients and help them navigate their recovery post-discharge. Chats were by-far the most liked feature from patients and care managers alike. Where chats helped was to make the patient-provider relationship on-demand – if a patient had a question– they could send a quick chat to the rehab staff and get a response. If staff saw that patients were doing well or not so well – they could detect issues quicker without waiting until patients showed up on-site again. Patients could ask questions any time of the day and get a response within 48 hours. Staff could modulate their responses. We firmly believe that every rehab facility should incorporate a chat or telephone-based follow up in the future as such an approach shows tremendous potential in amplifying the abilities of rehab staff beyond the four walls.

3) The power of flexibility - Especially during COVID-19, patients experienced several restrictions on their ability to travel or work outside. These restrictions allowed patients to be more open to trying alternative methods of receiving cardiac rehab. What was amazing was how, once introduced, patients quickly adapted and thrived in a home-based environment –patients started pursuing at-home exercise plans such as chair exercises and calisthenics. They regularly tracked and reported symptoms to rehab staff for advice and feedback. If they experienced symptoms or did not know how to do at ask, they asked for advice and got it. Crucially, we found that age was not a barrier to the use of technology-based approaches, in fact one of our most active patients was an 82-year old! When surveyed, patients indicated that the need to travel less was a huge benefit. As cardiac rehab facilities aim to become even more "consumer-centric," it is important to factor inpatient flexibility and accommodating schedules as another marker of success.Where technology-based approaches can plug the gap is in ensuring that a gap in physical attendance does not mean a gap in care.

4) The power of accountability - Prior to COVID-19, once patients left the rehab facility, staff had limited insight into how they were continuing their rehab at home.  With technology-based approaches, patients still had to exercise at home and report their information– else they would get a message from their care manager. This feedback loop created a sense of accountability. What was important to understand here is that accountability was not about shaming a patient if they were not compliant.In fact, tracking data was about providing a baseline for the beginning of a conversation – staff could review progress with patients and provide encouragement or problem solve. As opposed to relying on a lengthy recall procedure from the patient about their self-reported data, staff already had the information on hand and ready to review when they needed and could instead focus on their relationship. Technological tools such as apps or trackers lower the barrier for patients to track their progress and provide a ready reference for future discussions. They also reduce the need to pour over data by making transfer of data and the surfacing of insights instantaneous. Rehab facilities would be providing "super-powers" to their patients by giving them access to these tools.

Deploying across so many patients has allowed us to glean several insights into where technology fits and we think several of these approaches could continue during this time of the "new normal". Ultimately though, we learned a basic truth - that cardiac rehab is about the human connection. To the extent that technology disappears into the background while enhancing that connection, it would provide a job well done. We strongly encourage rehab facilities to imagine how some of the lessons learned could be applied in their context.