Feature ArticleA Mixed Methods Evaluation of the Feasibility and Acceptability of an Adapted Cardiac Rehabilitation Program for Home Care Patients
Introduction
Current healthcare reform encourages innovative approaches to care, particularly for patients with cardiovascular disease (CVD), the leading cause of death in the United States.1, 2 Cardiac rehabilitation (CR) utilizes exercise, education, counseling on behavioral change, risk factor modification, and psychosocial well-being to reduce morality and risk of hospital readmission.3 However, only 13.9% of acute myocardial infarction patients and 31.0% of coronary artery bypass graft surgery patients attend CR post-hospitalization, with very low attendance rates among heart failure patients as well.4, 5 CVD is especially prevalent among home care patients, a population that tends to be elderly, functionally impaired, and clinically complex.6, 7 Home care is often the first line of rehabilitation and support for elderly patients post-hospitalization, providing an opportune setting for interventions similar to those received by patients who attend outpatient cardiac rehabilitation (CR).8, 9 Home-based and center-based cardiac rehabilitation are equally effective in improving both clinical outcomes, with no difference between findings in the two settings in short term exercise capacity, systolic blood pressure, total cholesterol, smoking behaviors, and cardiac events.10 Despite these proven clinical outcomes, most home care agencies have yet to offer structured CR programs within their practice due to a lack of reimbursement mechanism and the logistical challenges of incorporating CR within the limitations of a home care episode.9 Furthermore, there is limited research focusing on frail, elderly patients in CR programs.11 The Middle-Range Theory of Self-care describes health-promoting practices required for chronic illness management, with the key concepts being self-care maintenance, self-care monitoring, and self-care management.12 This theory depicts the importance of promoting maintenance behaviors (such as preparing healthy food or coping with stress) as well as understanding the management of the chronic illness (such as understanding that shortness of breath due to heart failure may require taking an extra diuretic), which we incorporated into our intervention.12 Based on the Middle Range Theory of Self-Care of Chronic Illness, we explored the possibility that incorporating adapted CR into a certified home health agency may have a positive impact on patients' self-care management by increasing their awareness of CVD and how to manage it.12 The Home Heart Health (HHH) program is an innovative approach to delivering adapted CR services to patients with CVD within the context of a home health agency. The purpose of this study was to examine the feasibility and acceptability of the HHH program among patients and clinicians through qualitative interviews, and explore the impact of the intervention on patient self-care and knowledge of heart disease. We hypothesized that the HHH program will be accepted amongst patients and clinicians, and that the program will have a positive impact on patient self-care and knowledge of heart disease.
Section snippets
Design
A mixed methods design was used to evaluate the feasibility and acceptability of the HHH program, as well as explore preliminary patient outcomes. Patients and clinicians were recruited from a large not-for profit certified home health agency. Exploratory patient outcomes were assessed at 30-days post-baseline. Data on feasibility and acceptability were captured during qualitative interviews with patient and clinician participants. Qualitative data were collected during in-home patient
Participant characteristics
Patient characteristics and service use are shown in Table 3. The most common cardiac diagnosis code was for heart failure (40.0%), followed by aftercare for circulatory system surgery (22.2%), atrial fibrillation (20.0%), and coronary artery disease (11.1%). Of the patients enrolled for aftercare for circulatory system surgery (n = 10), four patients had undergone valve surgery and four patients had coronary artery bypass graft surgery. The remainder had an angioplasty or pacemaker insertion.
Discussion
This pilot study aimed to evaluate the HHH program, an adapted CR model for the home care setting, by exploring the programs' feasibility and acceptability. This study is based on current clinical barriers and implications, as well as a mid-range theory. The themes from the semi-structured interviews illustrated the feasibility and acceptability of the program, coupled with the patient survey data. Pre- and post-program surveys conducted with patients demonstrated improvements in the Self-Care
Acknowledgements
The authors thank the University of Pennsylvania President's Engagement Prize for supporting and funding the Home Heart Health initiative, and the Visiting Nurse Service of New York Center for Home Care Policy & Research for hosting the study. The authors also thank Dr. Barbara Riegel, School of Nursing, University of Pennsylvania, and the content experts from NYU Langone Health and Visiting Nurse Service of New York for their guidance and support. A special thanks to the patients and
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Funding source: University of Pennsylvania President's Engagement Prize