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3. EXPERIENCE

Chapter 15

Future Challenges

Ann-Dorthe Olsen Zwisler


15.1 Introduction

Based on scientific studies and our experience, cardiac rehabilitation is a key part of the overall future efforts to treat and prevent heart disease. This project has been implemented as an initiative to strengthen and develop this field.We have made considerable progress, but this field needs to be developed further.

Implementing the project has stimulated consideration on more fundamental aspects of cardiac rehabilitation. This chapter describes the subjective considerations of the cardiac rehabilitation team on a coherent cardiac rehabilitation programme, intersectoral cooperation and educational requirements in the future.


15.2 Ensuring A Coherent Cardiac Rehabilitation Programme

The comprehensive cardiac rehabilitation programme comprises not only the efforts of the Cardiac Rehabilitation Unit but can be divided into three phases that succeed one another in a continuous, chronological programme. The purpose, content and actors of each phase have specific characteristics (1).

Phase I is the introductory phase in which disease and treatment needs arise, diagnosis is made, acute treatment is initiated, the prognosis is assessed and the cardiac rehabilitation programme is planned. Phase II is the early phase in which rehabilitation is initiated and followed up. Phase III is the late phase of rehabilitation in which the initiatives are maintained and remission is prevented.

The comprehensive cardiac rehabilitation programme and action by various sectors
Illustration of The comprehensive cardiac rehabilitation programme and action
by various sectors

The programme is often based on activities by several actors in various sectors, and it is decisive that the patients consider the cardiac rehabilitation programme to be logical and coherent.


15.2.1 The cardiac rehabilitation programme

Phase I
Optimum cardiac rehabilitation in phase I and subsequent systematic clinical assessment and referral to phase II are prerequisites for a successful phase II hospital-based cardiac rehabilitation programme.

Experience from the cardiac rehabilitation programme at Bispebjerg Hospital shows that systematic assessment identifies many patients with heart disease or a high risk of heart disease who need systematic cardiac rehabilitation. Nevertheless, experience at Bispebjerg Hospital also shows that not all patients want or are well suited for a hospital-based outpatient cardiac rehabilitation programme. Elderly patients and patients with congestive heart failure especially have difficulty in taking a position on participating in a long programme with many visits to the hospital. Denmark offers very few alternatives to hospital-based outpatient treatment, such as home-based cardiac rehabilitation or, as in other countries, phase II inpatient cardiac rehabilitation.

Phase II
Repeated surveys of cardiac rehabilitation (3–7) have shown that the phase II outpatient cardiac rehabilitation programmes at Denmark’s hospitals needs to be expanded. The comprehensive cardiac rehabilitation project at Bispebjerg Hospital has shown that outpatient cardiac rehabilitation that complies with the existing guidelines for cardiac rehabilitation in Denmark (8–10) can be organized.

The cardiac rehabilitation team finds that an interprofessional approach requires a different organizational structure than the traditional hierarchical structure of hospitals and hospital departments, which tends to support the specialized profession-specific culture. One future challenge is therefore to develop an organizational design and a form of management for rehabilitation that better supports interprofessional methods of performing tasks and continuity in patient programmes across traditional professions and professional cultures while ensuring profession-specific excellence.

One alternative to hospital-based phase II cardiac rehabilitation is home-based cardiac rehabilitation, which may turn out to be just as effective as hospital-based programmes (11–15). Nevertheless, home-based cardiac rehabilitation requires well-functioning hospital-based programmes at which staff are based or from which staff can obtain experience and expertise. Experience with home-based cardiac rehabilitation in Denmark needs to be developed and assessed so that cardiac rehabilitation in the future can reach out to a broader target group than merely the relatively well-functioning patients who can manage to participate in the hospital-based programmes.

Phase III
At the end of phase II, it is very important that the patients can be referred to well-functioning phase III services with the aim of maintaining the effects achieved.

The practical experience in the Unit and a survey of cardiac rehabilitation (3) show that Denmark has very few phase III cardiac rehabilitation services. Similar to other countries, Denmark urgently needs to scale up phase III cardiac rehabilitation. Local health centres, which are currently being debated in Denmark, have been proposed as a vehicle for expanding phase III cardiac rehabilitation to local areas in other European countries (16).


15.2.2 Intersectoral cooperation

Attention has increased in recent years to the fact that patients are especially vulnerable during the transition between phases because coordination may be lacking between actors and activities (17). The problem is not solely that the intersectoral cooperation or lack thereof does not support the programme optimally. The most important prob- lem is that poorly functioning intersectoral cooperation adversely affects the otherwise positive activities within the individual phases and sectors.

Ensuring a coherent and optimum patient programme in the comprehensive cardiac rehabilitation programme has turned out to be difficult. This task becomes even more difficult when a coherent programme has to be coordinated across the various sectors. Clinical assessment and referral are an important aspect of ensuring intersectoral cooperation. Ensuring clear guidelines for assessment and referral procedures is key as well as establishing joint responsibility for implementing assessment and referral across sectors. The cardiac rehabilitation team believes that intersectoral cooperation will be able to be improved considerably in the future. Current models for strengthening cooperation include shared care (a model practised in the United Kingdom) and local health centres.


15.3 Educating And Training Staff

One of the most important lessons the cardiac rehabilitation team learned is that an interprofessional approach must be based on profession-specific excellence and on fundamental mutual respect among the professions involved.

Creating a formal educational programme within cardiac rehabilitation is a decisive aspect of realizing these aims. Education of the future, including educational programmes for specialists in cardiology, should require knowledge of and ability to manage cardiac rehabilitation. Ensuring professional excellence requires that the basic education and further education support this through well-documented methods, types of activities, documentation and evaluation within each profession. Successfully implementing cardiac rehabilitation in the future requires that basic assumptions on coherent cardiac rehabilitation programmes and on the necessity of interprofessional cooperation within various types of activity areas be shaped and profiled in connection with both basic education and further education.


15.4 Conclusion

Solid documentation exists on the effects of comprehensive cardiac rehabilitation (18–23), and there is broad professional, political and administrative consensus in Denmark that these services are an integral part of treatment (8–10;23–28). Despite this consensus, Denmark still has none of the desired specific national, regional and local implementation plans for cardiac rehabilitation activities (29).

The comprehensive cardiac rehabilitation project at Bispebjerg Hospital has demonstrated that hospital-based outpatient cardiac rehabilitation in accordance with existing national guidelines (8–10) can be organized in Denmark. This book comprises a model for an implementation plan that we hope can benefit health personnel and health planners in the field of cardiac rehabilitation.We hope that these activities will benefit Denmark’s heart patients so that all patients in need will be offered cardiac rehabilitation in the future.


References

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