Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.
Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.24 Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.
Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.25 Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.
Client-Clinician Partnership
The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.
Tailored Behavioral Change
The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.26 People are actively open to changing behaviors by only 20% at any given time.27 Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.
Discussion
Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.
A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.
Program Limitations
One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.
Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary.28
Conclusion
Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.
Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.