A Mixed Methods Evaluation of the Feasibility and Acceptability of an Adapted Cardiac Rehabilitation Program for Home Care Patients

Abstract

Home care clinicians have an opportunity to improve care for post-hospitalization patients with cardiovascular disease. This mixed methods study examined the feasibility and acceptability of an adapted cardiac rehabilitation (CR) program for the home care setting. Surveys measuring patient self-care and knowledge were administered to patients (n = 46) at baseline and at 30-day follow-up. Semi-structured interviews were conducted with patients (n = 28) and home care clinicians (n = 11) at completion of the program. All survey indicators demonstrated a trend towards improvement, with a statistically significant increase in the self-care management subscale (p = 0.002). Qualitative analyses identified three patient themes (self-awareness, nutrition, motivation) and three clinician themes (systematic approach, motivation, patient selection process). Incorporating CR into the home care setting proved to be a feasible and acceptable approach to increasing access to CR services among elderly 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.