Location For Delivering Cardiac Rehabilitation Programme

The goals of CR are to provide the patient and family with the individualised exercise prescription, counselling, education and support they need to resume an independent, active lifestyle. The majority of patients choose to participate in a clinically supervised phase III programme. They then progress into a long-term phase IV CR programme once they are stable and knowledgeable in self-monitoring and CHD risk factor modification.

However, not all patients are able to, or wish to, attend phase III CR sessions. They may choose to exercise at home because they do not wish to participate in a group, or because of problems of accessing the venue, inconvenience of the venue or programme timing, or because of the cost and time to travel to the programme. In order to overcome the absence of direct supervision and associated peer support, some CR services offer regular telephone contact and mail, fax or internet communication to support, monitor and advise patients through a home-based programme.

Although there is good evidence for the advantage of supervised exercise (Wenger, et al., 1995), home programmes have also been shown to be effective in increasing functional capacity and modifying risk factors (DeBusk, et al., 1994; Haskell, et al., 1994; Bell, 1998). A review of well-conducted randomised trials and observational studies supports findings that

Low to moderate intensity exercise for low to moderate risk patients can be provided as safely and as effectively in the home or community as well as in the hospital setting. Patients at high risk and those undergoing high intensity training should only exercise at venues with full resuscitation facilities and staff trained in advanced life support.

Increasingly, supervised phase III groups, traditionally held in the hospital setting, are held in the community. Phase III can also be structured to be sited in the hospital for the first half, and in the community for the second half of phase III CR (Armstrong, et al., 2004). This design helps to introduce patients early to a community setting, where phase IV will be based, thus exposing them to a less medical environment and using community facilities. In addition, these may be run as outreach programmes by hospital-based CR professionals, to improve access to services for patients and to overcome space and equipment limitations in hospital sites, or they may be staffed by community health professionals. Recommendations from a British Heart Foundation survey of all CR programmes in England and Wales (Fearnside, et al., 1999) encouraged a joint funding approach between hospital and community trusts in order to improve collaboration between and integration of services and to provide a more economical approach.

The challenge for CR professionals is to match the appropriate programme model to suit the individual patients' needs, overcoming any barriers and limitations, facilitating adherence, maximising benefit and delivering a quality, evidence-based service.

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