This example describes how the Wirral Cardiovascular Prevention and Rehabilitation Programme (CPRP) has integrated home-based rehabilitation (REACH-HF) through new delivery methods, prior to and during the COVID-19 pandemic, for patients with chronic heart failure.
Cardiovascular rehabilitation is indicated as an effective treatment option for patients with heart failure and is covered by multiple NICE guidelines and Quality statements (NG106; NG185; QS9).
Aims and objectives
- Improve patients’ ability to access sessions and complete core cardiovascular rehabilitation
- Improve patient referral into the rehabilitation programme from other settings
Reasons for implementing your project
Wirral has a population of around 320,000. The British Heart Foundation (BHF) statistics for Cheshire and Merseyside indicate that there were 32,000 people diagnosed with heart failure in 2020. These statistics also show that around 99,000 people in Cheshire and Merseyside are living with coronary heart disease (CHD) and around 410,000 people have been diagnosed with hypertension. Given that hypertension and CHD are the biggest causes of heart failure this shows that there are potentially many more people who could develop heart failure in the future should these risk factors not be managed. This clearly highlights the need for an effective CPRP to support health and wellbeing.
Cardiovascular rehabilitation is indicated as an effective treatment option for patients with heart failure and is covered within multiple NICE guidelines and Quality statements (NG106; NG185; QS9). Patients with heart failure are also a priority group for cardiovascular rehabilitation as detailed by the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) standards (2017).
Prior to commencing the Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) intervention, the Wirral CPRP had a long standing, robust programme for patients with a diagnosis of heart failure which had good attendance and completion rates.
From 2005 to 2014, the programme was run in a closed group format with all attendees engaging in seated based exercise. In 2014, higher functioning patients were offered the option of undertaking gym-based exercise. In 2016, the format was changed to a rolling programme until all patients with heart failure were integrated into the mainstream CPRP sessions in 2017 to improve accessibility and focus more on individually tailored programmes irrespective of diagnosis.
Despite the changes the programme had already undergone to improve accessibility, we were acutely aware that some patients were still not able to attend centre-based sessions. From patient feedback, lack of transport, or the inability to attend sessions was a main factor for patients with heart failure not completing core rehabilitation. There were also system issues, where patients were not referred into the CPRP from the community heart failure team, if the heart failure specialist nurse did not feel that the patient was suitable for exercise. Quantifying this was difficult however.
It was identified that within the service, all patients should be referred to CPRP from the community heart failure service so that the CPRP team could review suitability and commence suitable risk factor intervention and provide support, even if this did not include an exercise component. The service also wanted to ensure that patients were not being excluded from the service due to transport issues and providing rehabilitation closer to the patient’s home, or in their own homes, would be an ideal adjunct to centre-based care.
How did you implement the project
As we are an established CPRP, NICE and BACPR guidelines for cardiovascular rehabilitation were already well embedded in our programme. Within our wider Community Cardiology Service we have a Community Heart Failure Team who we work closely with and this also strengthens our link with our local hospital’s heart failure team to ensure we can get referrals from both sectors.
In order for the educational element of NICE guidelines to be met throughout the COVID-19 pandemic, we have recorded all of our educational talks and made them available online so that patients can access them remotely. To ensure that there is no digital exclusion, those who do not have internet access have been provided BHF literature based upon their personal risk factors in the post or at a home visit. All patients have the opportunity to ask questions during their telephone or home visit follow up appointments. Further work needs to be done to ensure that those with language or sensory needs are also fully met.
Budgetary funding had previously impaired the service from offering alternative home-based options. Wirral CPRP therefore submitted an application to be one of four beacon REACH-HF sites for the multicentre trial during 2019-2020 and were successfully chosen. Staff were keen to trial a new method of programme delivery.
Being a beacon site for the REACH-HF project, training for three facilitators was provided as well as 50 manuals. Following this, the service purchased a further 50 manuals from the service budget due to the success of the project and were also thanked for their time in supporting the roll out of REACH-HF training to other facilitators through additional manual provision.
From implementation of the project in August 2019 to end of December 2020, 113 patients have been referred to REACH-HF, with 59 completing the programme, 15 dropping out, 5 patients dying and 34 currently progressing through the programme.
Providing a home-based CPRP through REACH-HF has not increased time efficiency, and long-term will require sufficient funding to be allocated for manuals and any future facilitator training. For patients, REACH-HF has however enabled them to engage in a service which may have previously been inaccessible to them. As previously discussed, this has been particularly valuable throughout 2020. Patients have felt well supported and have enjoyed being able to engage family or loved ones in their care through the use of the family and friends resource. Staff have also enjoyed offering alternative methods of delivery and being able to utilise their skills in different settings.
Whilst it is difficult to quantify the impact on admission avoidance, especially through the COVID-19 pandemic, patients have been able to increase their exercise capacity (either through formal functional capacity testing, or throughout an increase in exercising level).
Key learning points
A home-based method of a CPRP is safe and effective for heart failure patients (Dalal, Taylor, Jolly et al., 2018). This has opened our eyes to expanding the remit of home-based or remote methods of delivery to other cardiovascular rehabilitation patient population groups without a diagnosis of heart failure, such as post myocardial infarction or revascularisation to support an increase in uptake and achieve the 85% target as detailed in the NHS Long Term Plan.
Identifying a longer project timeline would have been advantageous as we didn’t project the funding requirement for after the beacon site period had ended. Initial set up costs (i.e. facilitator training and manual outlay) were offset due to being a beacon site which was advantageous. Identifying budget to be utilised for new methods of delivery long term is important as well as submitting a clear business case to highlight the need for increasing access for this patient group and others.
Allocating specific time for facilitators to implement the REACH-HF programme is crucial if this is to be facilitated on top of usual clinical caseloads. Equally involving other members of the CPRP team in the facilitation of REACH-HF, for example exercise specialists and not just nursing staff, enables there to be a rounded team delivering the programme. Also, the inclusion of non-medical prescribers within the REACH-HF team would be beneficial to help to potentially reduce hospital admissions should the patient not be under the care of a heart failure specialist nurse.
Following successful application to become a Beacon site for the REACH-HF multicentre trial in 2019, the Wirral CPRP were provided with free training places to train up three members of staff to become REACH-HF facilitators. The Beacon sites were also provided with 50 free copies of the REACH-HF manual for the duration of the trial. The Wirral CPRP team were also approached by the REACH-HF research team to support the roll out of additional training to other CPRP teams, sharing their experiences and were provided with additional free copies of the REACH-HF manual in lieu of their involvement. This involvement is still ongoing.