Optimizing Function for Patients With Advanced Heart Failure

Researchers at the Mongan Institute Center for Aging and Serious Illness at Massachusetts General Hospital are developing and testing palliative rehabilitation models to optimize function and improve the quality of life for older adults with advanced heart failure.

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More than 6 million Americans live with heart failure, and it is advanced in about 10% of them. While advances in treatment have enabled people to live longer with the diagnosis, many experience substantial physical and psychological functional limitations.

Mass General's innovative approach applies a biopsychosocial model to rehabilitation, addressing both physical and psychological symptoms that impair function in patients with heart failure, says Tamra Keeney, DPT, PhD, a physical therapist in Mass General's Division of Palliative Care and Geriatric Medicine and a research scientist at the Mongan Institute Center for Aging and Serious Illness.

"Palliative rehabilitation is not really a topic of conversation yet in advanced heart failure," says Dr. Keeney, who leads the project. "We hope to create programs that are specifically tailored to meet the needs of older adults with advanced heart failure, to optimize function and allow them to participate in meaningful life roles and activities, even in the face of serious illness."

A Flexible Palliative Rehabilitation Model for Advanced Heart Failure

Palliative rehabilitation is not the traditional standard of care for patients with advanced heart failure. Yet there is a significant need to improve outcomes for these patients. "There's growing recognition that people with advanced heart failure experience substantial functional impairment and reduced quality of life," Dr. Keeney says. There are also distinct opportunities to incorporate palliative rehabilitation into their care. About a third of Medicare beneficiaries who are hospitalized for heart failure go on to receive home-based services, Dr. Keeney says. Another 25% or so are discharged to skilled nursing facilities.

"Ultimately, our goal is to develop a flexible palliative rehabilitation model that extends across settings," she says.

Initially, the project—called LiveWell-Heart Failure—will focus on home-based care. To develop the program, Dr. Keeney is working with her mentor, Christine S. Ritchie, MD, MSPH, the Kenneth L. Minaker chair in Geriatrics and the director of research for the Mass General Division of Palliative Care and Geriatric Medicine and the Mongan Institute Center for Aging and Serious Illness, Mass General cardiologists Erin Coglianese, MD, medical director of the Mechanical Cardiac Support Program, and Gregory Lewis, MD, section head of heart failure, director of the Cardiopulmonary Exercise Testing Laboratory, and medical director of the Cardiac Transplantation Program. To optimize the program for home-based settings, they are collaborating with Judith Flynn, MBA, BSN, RN, CHC, vice president of Patient Care Quality and compliance officer at Mass General Brigham Home Care and adjunct instructor in the School of Nursing at MGH Institute of Health Professions.

In an initial pilot project, the team is recruiting patients during hospitalization for heart failure, then re-evaluating them for a seven-week follow-up period to better understand how symptoms and functional impairments evolve over time following hospital discharge. The researchers are also conducting qualitative interviews with patients and their care partners to better identify unmet needs with regard to function and to learn about patients' prior experience with rehabilitation.

"This will allow us to design a rehabilitation model to better fit their needs. We'll take an iterative approach to engage with patients, their care partners, physical therapists, cardiologists and palliative care physicians to tailor the different components of the intervention," Dr. Keeney says.

Blending Rehabilitation Strategies With Psychological Skills

One innovative feature of the project is that it will address psychological symptoms as well as physical ones. "Patients with advanced heart failure often have underdiagnosed psychological symptoms, including depression and anxiety," Dr. Keeney says. She plans to supplement traditional rehabilitation strategies, such as exercise and mobility training, with psychological skills that were developed at Mass General for use in patients receiving palliative care for advanced cancer.

"The idea is to tailor these palliative care psychological skills to focus on adapting to functional loss, increasing care needs, and dependency on family members or other care partners, with the goal of optimizing the quality of life for people living with this progressive illness," Dr. Keeney says.

To appropriately incorporate psychological skills into the program, she is also mentored by Mass General psychologists Ana-Maria Vranceanu, PhD, founding director of the Integrated Brain Health Clinical and Research Program, and Joseph Greer, PhD, co-director of Cancer Outcomes Research & Education Program.

"We want to take the psychological skills from this integrated palliative care model, and tailor them to the strengths and scope of physical therapists," Dr. Keeney says.

To health care providers unfamiliar with physical therapy and rehabilitation, the idea might sound unusual. Yet physical therapists often draw on psychological skills to serve their patients.

"There are psychological aspects to every interaction that we have. There's an art in just getting patients out of bed and willing to participate in therapy during hospitalization," Dr. Keeney says. "And we regularly spend 30 or even 60 minutes with our patients—so we have the luxury of time to assess these symptoms and incorporate some of their treatments into our practice."

The idea is not without precedent. Over the past decade, there has been a movement to train physical therapists in principles of cognitive behavioral therapy and other psychological strategies to help patients manage the impact of chronic back pain, Dr. Keeney notes. "The critique of such programs is that it takes a lot of resources to train therapists in these techniques. But our idea is to develop a pragmatic solution that's intuitive to therapists and plays on some of the emotional and psychological skills we already use."

She envisions a future intervention that could be adapted for use by other specialists, such as occupational therapists, and speech and language pathologists. Rehabilitation clinicians frequently work with individuals with serious illness, yet don't receive robust training in palliative care principles, she adds. "It's valuable for us to think about how to interact with patients who are living with serious illness, for whom rehabilitation goals might be very different."

Advancing the Practice of Rehabilitation

Dr. Keeney became interested in this work years ago while working as a physical therapist in the advanced heart failure service at Barnes-Jewish Hospital in St. Louis, Missouri. There she began research on frailty and function in older adults, which led to a PhD focused on health services research. She joined the Center for Aging and Serious Illness in 2020 and has found it an ideal setting in which to combine her experience in health services research with her interest in developing and testing rehabilitation interventions.

"We're fortunate at Mass General that the role of rehabilitation is valued across service lines. Working within an integrated health system creates an opportunity to conduct really robust team science across disciplines," she says. She hopes this project will be part of a broader effort to integrate rehabilitation into patient care even more effectively.

Providing comprehensive palliative rehabilitation to patients with heart failure may not yet be standard of care, but it isn't as unusual as it may seem, Dr. Keeney says. "The New York Heart Association (NYHA) Classification, which is widely used to characterize the severity of heart failure symptoms, is focused on function. Palliative care is also very much focused on function and quality of life," she notes. "It makes sense to bring rehabilitation into the fold and work synergistically with other providers, so that we can advance the practice of rehabilitation and improve the ways we care for people with serious illness."

Learn about the Mongan Institute

Explore research at the Division of Palliative Care and Geriatric Medicine