Cardiac Rehabilitation: A Guide for Health Plan Leaders

Cardiac rehabilitation is a Class I recommendation from the AHA/ACC for patients following acute coronary syndrome, coronary revascularization, valve repair or replacement, heart failure, and heart transplant (Thomas et al., 2019). Yet national utilization remains stubbornly low — fewer than one in four eligible patients participate (Ades et al., 2017; Ritchey et al., 2020).

For health plan leaders, provider administrators, and cardiologists, the core question is which delivery model — or combination of models — best matches the clinical needs, access realities, and financial structures of your patient population.

This guide provides an evidence-based comparison of all four cardiac rehab delivery models — with sourced outcome data, cost considerations, a patient-selection decision framework, and operational trade-offs for payer and provider decision-makers.

A note on evidence and definitions:

The strength and maturity of evidence varies across delivery models. Center-based CR has decades of large-scale trial data. Home-based CR is supported by a robust Cochrane review. Virtual and hybrid models have a growing but more recent evidence base, drawn primarily from systematic reviews with heterogeneous study designs and, in some cases, single-program evaluations. Terminology also overlaps in the literature: some studies classify technology-supported home-based programs as “virtual” or “telerehabilitation,” while others use “home-based” to describe unsupervised exercise with periodic phone check-ins. Where studies blur these categories, we note the distinction. Where certainty is limited, we say so.

Key Facts About Cardiac Rehab

In This Article:

• Cardiac rehab reduces cardiovascular mortality by 20–26% and rehospitalization by 25–31% (Dalal et al., 2015; Anderson et al., 2016).
• Fewer than 24% of eligible patients participate nationally (Ritchey et al., 2020).
• A 2017 Cochrane review found home-based CR achieves comparable clinical outcomes to center-based programs across 23 trials (Anderson et al., 2017).
• CMS expanded coverage for virtual CR services through the 2025 Physician Fee Schedule rule, primarily through remote physiologic monitoring and telehealth visit codes. Commercial payer adoption varies by market and contract.
• The AACVPR published updated hybrid and virtual program standards in 2023, providing clearer accreditation pathways.
• Model selection should weigh patient acuity, geography, access barriers, evidence maturity, completion economics, and value-based care goals.

Why Cardiac Rehab Delivery Model Selection Matters Now

Systematic reviews demonstrate a 20–26% reduction in cardiovascular mortality and a 25–31% reduction in hospital readmissions among CR participants versus usual care (Dalal et al., 2015; Anderson et al., 2016). The AHA, ACC, and AACVPR jointly recommend CR as a standard of care following qualifying cardiac events (Thomas et al., 2019).

Despite this evidence base, CDC analyses have documented national CR participation rates below 24% of eligible patients (Ritchey et al., 2020).

Key Barriers to Participation:

• Geographic access: Many counties lack a certified CR facility, with rural patients facing the most severe shortages (Ades et al., 2017).
• Scheduling and transportation: Up to 36 sessions over 12 weeks during business hours creates conflicts with work and caregiving.
• Referral attrition: Approximately half of referred patients never attend a first session, driven by logistical barriers and delayed intake (Ades et al., 2017).
• Capacity constraints: Many center-based programs operate near capacity, limiting additional referral absorption.

The Four Cardiac Rehab Delivery Models

1. Center-Based Cardiac Rehab

Patients attend a certified outpatient facility two to three times per week for 12 weeks (up to 36 sessions). Each session includes ECG-monitored exercise, education, nutritional counseling, and psychosocial support under multidisciplinary clinical supervision.

Strengths: Established CMS reimbursement pathway with well-defined billing codes (CPT 93797/93798). Continuous ECG telemetry during exercise. Social support from group-based sessions. Strong evidence base supporting mortality and readmission reduction.

Limitations: Geographic reach limited to facility proximity. Reported completion rates fall between 25–40% (Ades et al., 2017). Scheduling rigidity and access barriers limit real-world utilization.

2. Home-Based Cardiac Rehab

Core CR components are delivered in the patient’s home, coordinated through periodic phone or telehealth check-ins. Patients follow structured exercise prescriptions independently between contacts.

Strengths: Eliminates transportation and scheduling barriers. Comparable clinical outcomes to center-based programs across trials.

Limitations: Less structured monitoring. Billing pathways vary significantly by payer.

3. Virtual Cardiac Rehab

Delivers all Phase II components through a technology-enabled platform — live video sessions with clinical exercise physiologists, remote physiologic monitoring via wearable devices, digital education modules, and real-time communication with a care team.

Strengths: Combines clinical structure with home-based accessibility. Expanding CMS reimbursement pathways.

Limitations: Requires patient access to broadband internet. Evidence base is newer and less extensive than center-based CR.

4. Hybrid Cardiac Rehab

Hybrid models combine center-based and virtual or home-based delivery. A common approach includes in-person sessions followed by virtual continuation.

Strengths: Supports baseline assessment and builds patient confidence. Aligns with updated AACVPR standards.

Limitations: More operationally complex. Reimbursement models are evolving.

Side-by-Side Comparison of Cardiac Rehab Delivery Models

Clinical Outcomes, Adherence, and Completion

All models, when delivered with guideline-aligned components, are associated with significant reductions in cardiovascular mortality versus no rehabilitation. Completion rates vary significantly across delivery models, with national data indicating that higher completion rates through structured follow-up enhance patient outcomes.

Economics: Cost, Reimbursement, and Value Implications by Model

Delivery model selection also has direct cost and value implications. Center-based CR typically incurs higher costs per completed patient compared to virtual CR, which may deliver equivalent outcomes at lower overall costs.

Selecting the Right Model: A Patient and Operational Decision Framework

No single delivery model is optimal for all patients or organizations. Common patient profiles and operational factors must be considered to maximize completion and benefit.

By Patient Profile:

By Operational and Financial Context:

Referral Workflow and Operational Considerations

The right cardiac rehab model is only as effective as the referral pathway connecting eligible patients to it. Reliable referral workflows are essential for enrollment and to reduce delays that affect patient initiation.

Conclusion

For health plans and health systems evaluating access to CR, understanding barriers to participation and delivery models is vital. Carda Health supports implementation and integration of virtual cardiac rehab as part of the broader spectrum of care pathways.