New England Health System Tackles Care Gaps with Aviary Health

A large health system in the Northeast implemented an AACVPR best practice — automated opt-out cardiac rehab referrals at discharge — across their hospital system to ensure that no eligible patient ever slipped through the cracks on their way to recovery.

Historically, cardiac rehab referrals have depended on a clinician remembering to act at exactly the right moment, creating a gap where thousands of eligible patients are discharged each year without ever being connected to rehab. By partnering with Aviary Health and working to embed automated referral orders directly into their EHR at the point of discharge, this large health system flipped the model. Likely-eligible patients are referred by default, and their providers must actively opt out of the referral if not appropriate for each individual patient. The results in the first year were striking: referrals to cardiac rehab grew by approximately 168%, unique patients enrolled in CR increased by over 50%, and total CR sessions completed rose by 71%.