Cardiovascular disease (CVD) remains the leading cause of death in the United States. Due to significant advances in health care, there is an increase in the number of individuals living with CVD. These individuals may struggle with self-management and symptom control, and 25% patients with heart failure discharged from the hospital are readmitted within 30 days. CVD is a particularly diagnosis common among the home care population, with heart failure (HF) and acute myocardial infarction/ischemic heart disease as leading conditions. Home care clinicians are often the first line of rehabilitation and support for patients post-hospitalization. An adapted home-based cardiac rehabilitation (CR) represents a promising approach to improving care and reducing hospital readmissions among patients with CVD. The services of CR can reduce all-cause mortality and cardiac mortality rates, and benefit patients through exercise and modifications of controllable risk factors. Despite the clinical effectiveness of CR, participation rates in these programs remain low. There is a need for alternate models of secondary preventative cardiac care to increase adherence to CR services and prevent poor outcomes. Home-based programs are potentially an effective and low-cost method of care. However, there are limited evidence-based evaluations that home care agencies are implementing the core competencies of CR programs into their episodes of care and that home care clinicians receive education on these competencies.

Our pilot program, Home Heart Health, is an adapted CR program for the home care setting. Home Heart Health is an interdisciplinary CR program that emphasizes CVD risk factor modification and management for home care patients. In our program, home care registered nurses, physical therapists, and occupational therapists were educated to provide adapted CR services to patients as a complement to traditional home care. This training for home care clinicians was adapted from the American Association of Cardiovascular and Pulmonary Rehabilitation professional core competencies for outpatient CR. It was developed based on literature and guideline reviews, as well as themes identified among patients and clinicians. During the program, patients received visits from these home care clinicians, who provided an exercise plan, nutrition counseling, and self- management education, with accompanying patient teaching tools. Clinicians practiced in accordance with standardized interventions checklists. We conducted a multi-phase study to develop, implement and evaluate this adapted CR program.

The first phase of the pilot was to develop and implement the CR training program adapted for home care clinicians, incorporating the viewpoints of homebound patients with cardiovascular disease. Literature and guideline reviews were performed to glean curriculum content, supplemented with themes identified among patients and clinicians. Semi-structured interviews were conducted with homebound patients regarding their perspectives on living with cardiovascular disease and focus groups were held with home care clinicians regarding their perspectives on caring for these patients. A questionnaire was administered to home care nurses and rehabilitation therapists and compared for pre- and post-training. Three themes emerged among patients: (1) awareness of heart disease; (2) motivation and caregivers’ importance; and (3) barriers to attendance at outpatient CR; and 2 additional themes among clinicians: (4) gaps in care transitions; and (5) educational needs. Questionnaire results demonstrated significantly increased knowledge post-training compared with pre-training among home care clinicians. There was no significant difference between scores for nurses and rehabilitation therapists, indicating the feasibility of interdisciplinary training. As a result of this study, we concluded that home care clinicians respond well to an adapted CR training to improve care for homebound
patients with cardiovascular disease. Clinicians who participated in the Home Heart Health
training demonstrated an increase in their knowledge and skills of the core competencies for CR. Read the full manuscript depicting the development and implementation of the Home Heart Health program and training for clinicians here.

The second phase of the pilot was to conduct a mixed methods analysis to determine the
feasibility and acceptability of Home Heart Health. Surveys measuring patient self-care and
knowledge were administered to patients at baseline and at 30-day follow-up. Semi-structured interviews were conducted with patients and home care clinicians at completion of the program. All survey indicators demonstrated a trend towards improvement, with a statistically significant increase in the self-care management subscale. Qualitative analyses identified three patient themes: (1) self-awareness; (2) nutrition; and (3) motivation; and three clinician themes: (1) systematic approach; (2) motivation; and (3) patient selection process. We concluded that incorporating CR into the home care setting proved to be a feasible and acceptable approach to increasing access to CR services among elderly patients. As acute care transitions to the home and outpatient settings, coupled with efforts to meet patients were they are, studies demonstrating the feasibility of alternative methods to care are vital. Our pilot study supports the need for further testing with a larger sample to determine the efficacy of adapted cardiac rehabilitation for the home care setting. Read the full manuscript examining the feasibility andacceptability of Home Heart Health here.

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