Specifying a cardiac rehabilitation service

Service components

The key components of a cardiac rehabilitation service are:

• systematically identifying and actively engaging people potentially eligible for cardiac rehabilitation
• developing a high-quality comprehensive cardiac rehabilitation service.

Systematically identifying and actively engaging people potentially eligible for cardiac rehabilitation

Poor referral, take-up and attendance have been identified as problems facing cardiac rehabilitation services in the UK. There are several reasons for the lower than expected levels of participation. These include a lack of engagement (people not invited to attend cardiac rehabilitation), low levels of referral, scarcity of service provision and poor take-up due to practical reasons (for example, location and time of the session).

NICE clinical guideline CG48 on MI: secondary prevention makes the following recommendations for improving engagement and take-up of cardiac rehabilitation services.

• Healthcare professionals, including senior medical staff involved in providing care for patients after an MI, should actively promote cardiac rehabilitation. All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component. Patients with left ventricular dysfunction who are stable can safely be offered the exercise component of cardiac rehabilitation.
• Cardiac rehabilitation should be equally accessible and relevant to all patients after an MI, particularly people from groups that are less likely to access the service. These include people from black and minority ethnic groups, older people, people from lower socioeconomic groups, women, people from rural communities and people with mental and physical health comorbidities.
• Cardiac rehabilitation programmes should include an exercise component designed to meet the needs of older patients or patients with significant comorbidity. Any transport problems should be addressed.
• Reminders such as telephone calls, telephone calls in combination with direct contact from a healthcare professional, and motivational letters should be used to improve uptake of cardiac rehabilitation.
• Healthcare professionals should ask patients whether they would prefer single-sex classes or mixed classes.

Where cardiac rehabilitation services have been adequately resourced and where they have systematically identified people and adopted a structured approach to their work, the numbers of people treated have increased. Trust-wide protocols that specify the arrangements for identifying appropriate patients and that specify agreements with primary care trusts about the groups of patients who are to be offered cardiac rehabilitation can be found in the ‘National service framework for coronary heart disease'. Once trusts have an effective system for identifying, treating and following up people who have survived an MI or who have undergone coronary revascularisation commissioners may wish to consider extending cardiac rehabilitation services to include people with stable angina and heart failure, and those who are undergoing specialised interventions such as cardiac transplant and implantable cardioverter defibrillators (see ‘Implantable cardioverter defibrillators for arrhythmias' NICE technology appraisal 95).

In addition cardiac rehabilitation services may need to accept referrals from clinicians working in other localities; these may include people who have been admitted to hospital far from where they live, for example, those having surgery at a specialist centre or people who have suddenly become unwell while away from home.

Developing a high-quality comprehensive cardiac rehabilitation service

A prime aim of a cardiac rehabilitation programme is to provide a set of services tailored to the needs of each patient based on a comprehensive assessment of their cardiac risks. The range of options is described in NICE clinical guideline CG48 on MI: secondary prevention and include:

• health education and information
• advice on lifestyle: diet and weight management, physical activity and exercise, smoking cessation and alcohol consumption
• psychological and social support
• cultural and vocational needs
• family and carer needs.

Patients should be encouraged to attend all services appropriate to their clinical needs and should not be excluded from the entire programme if they choose not to attend certain components.

Some patients may benefit from a home based comprehensive cardiac rehabilitation programme validated for patients who have had an MI (such as ‘The Edinburgh heart manual') that incorporates education, exercise and stress management components with follow-ups by a trained facilitator. It should be offered to patients as part of a menu based approach but should not be used to replace a multi-disciplinary hospital based programme, as some patients prefer to exercise in hospital and others will have complex conditions that need specialist assessment. A home based programme produces similar gains to hospital programmes and has been shown to be preferred by many patients. The term ‘home-based programme' is applied to a variety of methods but any programme purchased should have a published evidence base and attend to lifestyle change and psycho-social adjustment.

The British Association for Cardiac Rehabilitation document 'Standards and core components for cardiac rehabilitation' recommends a multidisciplinary approach to cardiac rehabilitation consisting of trained and competent staff. These would include a service lead with overall responsibility for the service, a cardiac specialist nurse, physiotherapist, dietician, occupational therapist, administrator and part-time designated clinical lead (for example, a cardiologist or GP with a special interest in cardiology). The team should also include, where appropriate, a pharmacist and a physical activity/exercise specialist, and incorporate referral to a psychologist.

Commissioners may wish to consider commissioning a district wide cardiac rehabilitation service across the four phases described in the ‘National service framework for coronary heart disease'. Cardiac rehabilitation should begin as soon as possible after someone is admitted (or planned to be admitted) to hospital with coronary heart disease (CHD) (phase 1), continue through the early post discharge period (phase 2) and the formal rehabilitation service (phase 3) and extend into long term maintenance (phase 4). Primary care trusts, local authorities and the voluntary sector should agree the range and availability of services that can be drawn on for cardiac rehabilitation. For example, local authority leisure centres, church halls or other easily accessible public venues may be appropriate for cardiac rehabilitation sessions, and appropriately trained local authority staff can play a useful role in supervising physical activity and supporting exercise-on-prescription schemes.

Commissioners may wish to consider commissioning a cardiac rehabilitation service in a number of different ways, and mixed models of provision may be appropriate across a local health economy. Commissioners may also wish to collaborate with the local cardiac network to ensure a strategic approach to service development.

There are many examples and models of cardiac rehabilitation services. ‘Cardiac rehabilitation', supported by the British Heart Foundation, provides names and addresses of cardiac rehabilitation services throughout the UK. A cardiac rehabilitation service in Cornwall demonstrates that national service framework targets for cardiac rehabilitation and secondary prevention can be achieved in patients who survive a MI by integrating rehabilitation services (home and hospital) with secondary prevention clinics in primary care. Nurse led clinics in primary care facilitate long term structured care and optimal secondary prevention. Payments for these clinics are now included in the new GP contract as part of the ‘Quality and outcomes framework'. This example is offered to share practice and NICE makes no judgement on the compliance of this service with its guidance.

Local stakeholders, including service users, carers and family members should be involved in determining what is needed from a cardiac rehabilitation service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people/patients with CHD.

The service specification needs to consider:

• the required competencies of, and training for, staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways
• information and audit requirements, including IT support and infrastructure
• planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times
• service monitoring criteria.

Useful sources of information may include:

• The NICE ‘shared learning' database offers examples of how organisations have implemented NICE guidance locally.
• Implementation advice for NICE clinical guideline CG48 on MI: secondary prevention.
• NICE technology appraisal guidance 95: Implantable cardioverter defibrillators for arrhythmias.
• Scottish Intercollegiate Guidelines Network clinical guideline 57: ‘Cardiac rehabilitation'.
• ‘Standards and core components for cardiac rehabilitation' produced by the British Association for Cardiac Rehabilitation.
• ‘Heart Improvement Programme cardiac networks' supports the development of cardiac networks and ensures the spread of service improvements.
• The ‘Map of medicine' provides an information resource that visually organises the latest evidence and best practice guidelines.
• Heart Improvement Programme.
• Prevention, treatment and rehabilitation of cardiovascular disease in South Asians provides advice on prevention, treatment and rehabilitation of CHD patients, especially tailored to South Asian patients.
• ‘Heart disease and South Asians: delivering the national service framework for coronary heart disease'.