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Chapter 4

Individually Tailored Rehabilitation

Marianne Frederiksen & Pernille Kriegsbaum

4.1 Introduction

One main principle of cardiac rehabilitation is that treatment should be individually tailored for each patient (1–4). This principle is considered to be a key element in the future organization of cardiac rehabilitation (5), and modern cardiology emphasizes this as the organizational focus of treatment (6). Previous assessments of the achievement of goals in European countries have shown that the traditional arrangement of rehabilitation has been inadequate to achieve the goals set (7;8), and recent studies on cardiac rehabilitation (9;10) have shown that individually tailored programmes achieve goals better and are cost-effective.

The Cardiac Rehabilitation Unit at Bispebjerg Hospital tailors patients’ rehabilitation programmes based on individual consultation with a physician, a clinical dietitian, a physical therapist and a nurse followed by an interprofessional conference that establishes the final goals of treatment based on the needs and resources of each patient. This chapter describes the individual consultations and the interprofessional conferences.

4.2 Methods

4.2.1 Principles

The programme is individually tailored and the individual consultation is performed based on several consistent principles.

Patient-centred communication
The professionals attempt to carry out the consultation based on the principles of equality, empathy and responsiveness. The dialogue is based on the individual patients and attempts as much as possible to identify the patients’ needs and resources. The professionals ensure that patients understand the information provided, and oral information is supplemented with relevant written information to the extent patients desire this. The clinical team tries to disseminate uniform information to avoid confusion and uncertainty about the messages among patients.

The clinical team generally tailors the amount of information to the patients’ needs and resources. Lack of knowledge and uncertainty on treatment and illness can result in anxiety, whereas patients can stay calm if they feel well informed. Conversely, too much information may upset patients. Many patients prefer to have oral information supplemented with written information that they can review at home. Nevertheless, some patients have difficulty reading and would therefore mainly benefit from material with images, including film and video. They may benefit from seeing a film focusing on their current situation. The Cardiac Rehabilitation Unit finds that patients increasingly use the Internet to search for information. The task of the clinical team is to refer to patient-friendly material on the Web that is in accordance with the information disseminated in the programme.

Continuity in the treatment programme
The programme emphasizes ensuring that patients experience a coherent treatment programme. At the first appointment, patients are informed about the programme, the time frame and the order of the various activities in the comprehensive cardiac rehabilitation programme. Patients are regularly informed when changes are made.

Responsibility and division of labour
The roles and responsibilities of the clinical team members are an important part of the programme. The professionals briefly describe their background and role during the patient’s programme at the Cardiac Rehabilitation Unit the first time each patient meets each professional.

The nurse is the key staff member in each patient’s individual programme. The nurse is also responsible for coordinating the Unit’s interprofessional approach.

The nurse and physician review many of the same items in the individual consultation; the physician especially focuses on the patients’ history and course of illness and the nurse more on the patients’ psychosocial well-being.

Documentation and quality assurance
The Cardiac Rehabilitation Unit uses joint electronic patient records to coordinate and optimize the interprofessional approach.1 The treatment activities and quality assurance of the treatment are documented through structured record notations and systematic data registration. As part of the individual consultations, the goals of treatment, treatment plan and any changes are registered so that this information is available at the subsequent consultations and the interprofessional conferences.

Heart-health orientation binder
A heart-health orientation binder published by the Danish Heart Foundation is given to the patients. Patients are encouraged to bring the heart-health orientation binder to individual consultations. All written material provided by the Unit is designed in a format that fits the binder.

Preparation for individual consultation
The staff members are prepared for the planned individual consultations in the cardiac rehabilitation programme so that the patients experience presence and commitment. Time is set aside for preparation immediately before the consultations so that all professionals are reminded of the patient’s illness history, lifestyle and psychosocial factors, test results, biochemical data, pharmaceutical treatment, treatment goals and treatment plan.

Appointment and time used
Patients referred to the programme are ideally appointed to the first consultation with a physician 1 week after referral. After the physician, the patient consults the physical therapist and the dietitian. The consultation with the nurse is the last in the series of introductory individual consultations.

The initial consultations are allocated 60 minutes, including preparation, discussion, record-keeping and administration. The patients are informed at the start of the consultations on their purpose and time frame.

4.2.2 Administration of individual programmes

The secretary coordinates the four individual consultations and the start of group sessions in the intensive 6-week programme.

Administration of individual programmes

Tilrettelæggelse af individuelt forløb

Notifying the patient: The Unit sends a welcoming letter to the patient in connection with the placement of the patient in the physician’s schedule. The letter includes the time of the consultations with the physician, physical therapist, dietitian and nurse. A welcoming letter is included that describes the treatment programme and a guide for various clinical tests and examinations (the welcoming letter, brochures and appointment card are available in Danish at www.CardiacRehabilitation.dk). Family members (especially spouses) are invited to participate in all individual consultations.

Group sessions: PPatients who will be attending group sessions are notified of the start of group sessions when five to eight patients are ready. The patients’ desires for starting time are taken into account. Patients attend planned activities of 2–5 hours per day twice a week for 6 weeks.

The Unit sends the patient an appointment card with an overview of appointments and activities. If individual follow-up appointments are needed, these are coordinated with the other appointments to minimize the number of trips to the Unit.

Administration: The secretary ensures that the patients are entered into the electronic administrative system (the joint electronic patient records). Group sessions are administered in an electronic patient database (the DANREHAB database) developed as an administrative tool to manage patient appointments, the creation of groups and the dissemination of letters and evaluation forms. The information is maintained and updated regularly. The secretary ensures that the necessary papers, including patient records and material related to assessment and referral, is present and updated at the first appointment.

4.2.3 Individual consultation with a physician

The purpose of the initial individual consultation is to assess patients’ overall health based on their diagnoses, severity of illness, symptoms, risk profile, lifestyle, physical functioning and psychosocial well-being and to organize an individually tailored rehabilitation programme based on individual treatment goals.

The consultation
The physician prepares an assessment report based on the patient’s hospital records that comprise the basis for the consultation. The consultation is structured based on a specific interview guide (available in Danish at www.cardiacrehabilitation.dk).

Summary of illness history and course of illness: The physician and the patient review the patient’s current illness history that resulted in the referral to the comprehensive cardiac rehabilitation programme. This review is based on the assessment report, and patients can ask questions and provide additional information.

Test results: The patient is informed about the tests performed and their purpose. Medical terms often need to be explained. A metaphor is used to describe technical terms such as ejection fraction. Imagine that the heart is like a pump in the shape of a balloon and is filled with 100 ml of water. Every time you squeeze, 60 ml of water is ejected [ejection fraction 60%]. This is about how much blood the heart pumps out. If you squeeze the balloon less, only 40 ml is ejected [ejection fraction 40%], and this means that the heart has lost some of its ability to pump.

Other diseases and disorders: The physician systematically gathers information on other diseases and disorders that can influence the rehabilitation programme to assist in individual tailoring of programmes. The presence of arthritis or rheumatism or other musculoskeletal disorders may affect the organization of the exercise training. The physician informs the patient about the links between heart disease and related diseases. Such diseases as stroke before myocardial infarction or intermittent claudication are related both to one another and to the risk factors for cardiovascular disease.

Risk profile: The patient’s overall risk profile for cardiovascular disease is reviewed using the interview guide based on the available information. If information is missing, this is collected. The links between heart disease and the classical risk factors are reviewed briefly. Many patients learn for the first time that serum cholesterol is associated with smoking, overweight and physical inactivity, and many patients believe that high blood pressure is not related to heart disease.

The metabolic syndrome: The metabolic syndrome comprises several risk factors for cardiovascular diseases, the key ones being overweight, elevated blood pressure and high serum cholesterol. This syndrome has several definitions, but the Cardiac Rehabilitation Unit diagnoses based on WHO recommendations, and the syndrome diagnosis is used as a concept for improving the ability to trace and stratify by risk the patients with the highest risk, who often (but not always) have type 2 diabetes mellitus or impaired glucose tolerance (11;12).

Physical and mental well-being since discharge: Patients are asked how they are doing, such that the patient has the opportunity to describe minor health problems. Patients are then asked to assess their overall health. The physician asks about other cardiovascular problems, such as angina pectoris, breathlessness, ankle oedema, dizziness and palpitation. The links between heart disease and these various problems are explained when needed. Patients are asked about any symptoms of anxiety, mood swings and/or difficulty in sleeping to determine whether the patient has latent depression.

Social situation: The physician asks about previous or current employment, domestic activities and leisure pursuits, friends and family and determines whether the patient has given up any activities. Patients are asked about publicly subsidized services (such as home help or a personal alarm), sickness benefit and pension information. The patient is informed about the opportunity to consult a social worker. Finally, patients with driving licences are informed about the rules for driving among people with cardiovascular disease based on guidelines prepared by the Danish Society of Cardiology (13).

Sick leave: The physician determines the need for any sick leave and its duration at the first session. The sick leave should be as short as possible and account for cardiovascular status and the physical and mental demands of the employment. Most patients with myocardial infarction are on sick leave for 3–4 weeks after discharge. Some patients with light work that has low physical demands can return to work after 1–2 weeks.

Pharmaceutical treatment: The patient’s pharmaceutical treatment is reviewed, including natural medicine. The physician ensures that the patient receives and is complying with prophylactic medicine (Chapter 10). Many patients have difficulty in managing the numerous pharmaceutical products, and the cost of the user charges may be a problem. The patients are informed about rules for public subsidies, the purpose of the treatment and, if possible, the duration of the treatment. If necessary, the use of nitroglycerin is explained.

A physical examination: A cardiological examination is performed with inspection of the thorax and any surgical scars, stethoscopy of the heart, lungs, carotid and inguinal blood vessels, blood pressure measurement, inspection and investigation of the pulse on the lower extremities. The patient is weighed.

The physical examination is placed at the end of the consultation since the patient and physician usually build trust during the consultation. The physician summarizes such topics as overweight, elevated blood pressure and physical activity, and such topics as sex life and anxiety are also discussed.

Establishing treatment goals: Optimum treatment goals are established based on the information gathered and considering the patient’s diagnosis within the areas of symptomatic and prophylactic pharmaceutical treatment, risk factor management, lifestyle and level of functioning.The physician and patient discuss the treatment goals.

The following table presents the guidelines for ideal treatment goals based on Denmark’s current guidelines for each area. If a patient’s situation applies to several areas, such as having both ischaemic heart disease and type 2 diabetes, the most restrictive treatment goals apply.

Ideal treatment goals in the comprehensive cardiac rehabilitation programme
- type 2 diabetes
- type 2 diabetes
Type 2 diabetes
Type 2 diabetes
High risk
- type 2 diabetes
Symptomatic treatment No angina
NYHA classes I–II
No angina
NYHA classes I–II
Fasting blood glucose
Hg A1c < 6.5%

Blood pressure (mmHg) <140/90 <130/80 <120/75 <140/90
Serum cholesterol

Total (mmol/l)




LDL (mmol/l)




HDL (mmol/l)




Triglycerides (mmol/l)






<25 kg/m2

<25 kg/m2

<25 kg/m2

Waist male/female <94 cm/<80 cm <102 cm/<88 cm <102 cm/<88 cm

Physical activity

30 minutes
per day.

30 minutes
per day.

[see note]

30 minutes
per day.

[see note]

Dietary habits

Heart-healthy diet

Type 2 diabetes diet

Heart-healthy diet

Smoking Nonsmoker Nonsmoker Nonsmoker
Level of functioning

Physical Maximally optimized Maximally optimized Maximally optimized
Psychological Maximally optimized Maximally optimized Maximally optimized
Social Maximally optimized Maximally optimized Maximally optimized
CHF = congestive heart failure
IHD = ischaemic heart disease
NYHA = New York Heart Association classification system
Hb A1c = glycosylated haemoglobin A
LDL = low-density lipoproteins
HDL = high-density lipoproteins
BMI = body mass index

The guidelines on treatment goals are based on guidelines from Denmark and elsewhere. The Department of Cardiology has prepared local guidelines on treatment that summarize the current guidelines in Denmark and elsewhere (available in Danish at www.klinik-y.dk).

The values for ideal treatment of elevated blood pressure and elevated serum cholesterol have changed in recent years (14–19), which has resulted in more intensive treatment of patients with heart disease and type 2 diabetes and of patients with a high risk of heart disease.

Treatment plan: The consultation ends by establishing a treatment plan that considers patients’ experience, needs, resources and motivation. The physician and the patient complete the plans for treatment and results in the heart-health orientation binder.

The physician emphasizes to patients the significance of and effects of lifestyle intervention, and the extent of their motivation for intervention is determined in the initial consultations with the physical therapist, dietitian and nurse, who manage this part of the treatment. The physician specifies in the treatment and results plan whether risk factors should solely be managed using lifestyle intervention: for example, treating slightly elevated blood pressure by exercise training alone.

The physician decides whether pharmaceutical treatment needs to be further assessed or initiated or changed. Finally, the physician reviews the absolute and relative contraindications for carrying out the aerobic functioning test and participating in exercise training and decides whether the test should be carried out with normal or extended precautionary procedures (these procedures are available in Danish at www.CardiacRehabilitation.dk).

Contraindications for exercise training or aerobic functioning test (32;34)
  • Acute ischaemic heart disease stabilized for less than 5 days
  • Resting apnoea
  • Pericarditis, myocarditis or endocarditis
  • Symptomatic aortic stenosis
  • Severe hypertension
  • Fever
  • Thrombophlebitis
  • Class IV of the New York Heart Association classification system

4.2.4 Individual consultation with a physical therapist

A key aspect of the programme is optimizing patients’ physical functioning and ensuring that they are active in daily life to prevent future heart problems. The clinical team must therefore have extensive knowledge of this area.

The patient has an individual consultation with a physical therapist. This consultation is immediately after the initial consultation with a physician and includes an aerobic functioning test. The physical therapist prepares by focusing special attention on any contraindications for exercise training and whether patients receive pharmaceutical treatment that can influence exercise training.

The purpose of the initial consultation is to jointly plan the exercise training programme based on the patient’s needs, resources, experience and motivation to be physically active in daily life and the opportunities to implement exercise training in the activities of daily living, including exercise training at work.The physical therapist strives to get the patients to set the goals for their physical rehabilitation, which are not set in stone but are regularly adjusted jointly by patients and the physical therapist. The physical therapist supports patients in setting realistic goals, guides the patients towards achieving these goals and apply any corrective measures necessary.

Physical activity levels
  1. Nearly sedentary: <2 hours per week
  2. Light physical activity 2–4 hours per week
  3. Modeate physical activity >4 hours per week
  4. Strenuous physical activity >4 hours per week
Note: The recommendation on physical activity changed during the study period from 4 hours of moderate physical activity a week to >30 minutes per day (31–33).

Initial consultation
The initial consultation with the physical therapist is carried out based on patient records and is structured based on an interview guide (available in Danish at www.CardiacRehabilitation.dk).

Determining the level of physical activity: The consultation is used to quantify the patients’ daily and weekly level of activity based on self-report and to place them in one of the four groups above. The patients describe their daily physical activity.

Problems related to physical activity: Patients are asked whether they have musculoskeletal symptoms from physical activity.They are also asked about any difficulty in breathing, whether they are anxious about exercise and the thoughts they have in relation to this anxiety.

Experience with physical activity: Patients’ experience with physical activity is determined with the aim of focusing on positive experience and avoiding reinforcing negative experience. Any specific exercises that are not carried out are reviewed and noted.

Patients’ goals for physical activity: Patients are encouraged to set their own goals for exercise training in the 6-week exercise training programme and in their activities of daily living. Examples of patients’ goals for activities of daily living include getting to Tivoli without help or cycling to work instead of driving.

Test of aerobic functioning: All patients take a test of aerobic functioning. The test is used to stratify patients in terms of risk and also has a health education aim for the patients who are anxious about activity and physical effort. The test is further carried out to assess patients’ aerobic capacity to assist in establishing individual exercise training programmes and a basis for biofeedback related to exercise training and in evaluating exercise training.

Patients carry out a maximum symptom-limited aerobic functioning test on an exercise cycle. If the test cannot be performed because of contraindications or because the patient cannot cycle, the patient walks for 6 minutes. Both tests are performed based on a set procedure that ensures patient safety (available in Danish at www.CardiacRehabilitation.dk). The procedure is based on the guidelines for clinical exercise testing in relation to ischaemic heart disease of the Danish Society of Cardiology (34).

Setting treatment goals: The treatment goals are set together with the patient based on the consultation and the aerobic functioning test. It is decisive that the patients define their own goals for exercise training, both in the six-week programme and in activities of daily living, and this is therefore a key aspect of the consultation.

The overall goal for physical activity in daily life is light physical activity 30 minutes per day in accordance with the guidelines of the National Board of Health. The goal is to get all patients up to this level regardless of their starting-point. Patients who have the potential can set a more extensive goal.

An individually tailored exercise training programme is set based on the initial consultation and the aerobic functioning test, including the level of exercise training based on heart rate response and effort achieved during the test (the procedure is described in Chapter 6).

4.2.5 Individual consultation with a clinical dietitian

A heart-healthy diet is a cornerstone of the comprehensive cardiac rehabilitation programme. The clinical team must therefore have extensive knowledge of patients’ dietary habits and the clinical dietitian must therefore consult individually with all patients.

The purpose of the consultation is to determine each patient’s current dietary habits and individual dietary problems and to arrange an individually tailored programme of dietary change based on individually established treatment goals.

The initial consultation: The initial consultation with the dietitian is carried out based on patient records and is structured based on an interview guide (available in Danish at www.CardiacRehabilitation.dk).

Determining dietary habits and examining nutritional status. The dietitian gathers information on the patient’s dietary habits by obtaining a detailed dietary history and by examining nutritional status, including registration of weight and waist circumference.

Medicine and diet: The patient’s medicine is reviewed to determine whether any pharmaceuticals can influence weight or interact with foodstuffs. For example, antidepressants can cause weight gain and antiplatelet drugs may interact with foodstuffs rich in vitamin K1 (Chapter 7).

Review of the principles of a heart-healthy diet: The principles of a heart-healthy diet include reducing fat intake, especially saturated fat and trans-fatty acids, increasing intake of fatty fish, eating 500–600 grams of vegetables and fruit per day and reducing salt intake. The review focuses on the areas in which the patient needs to change dietary habits.

Agreement on dietary change: Based on the information gathered and the patient’s motivation, the dietitian and patient enter into a written agreement on dietary change and/or weight loss, which the patient places in the heart-health orientation binder (the agreement form for weight loss is available in Danish at www.CardiacRehabilitation.dk).

The dietitian determines whether each patient needs an individually tailored dietary rehabilitation programme with the dietitian to supplement group sessions. Individual programmes are relevant if the patient is overweight, has type 2 diabetes, is quitting smoking, has recently starting pharmaceutical treatment known to cause weight gain or has a risk of undernutrition (assessed through body mass index, progressive weight loss and food intake (35)).

4.2.6 Individual consultation with a nurse

The nurse’s coordinating role requires the nurse to have a comprehensive overview of each patient’s course of illness and treatment, health resources, motivation for changing lifestyle and psychosocial situation. Each patient therefore has an individual consultation with a nurse as part of organizing the individually tailored programme.

This consultation, which is the last of the four initial consultations with the clinical team, takes place within the first week of the intensive programme. An early consultation ensures that the patient does not brood over unanswered questions and is the basis for optimum coordination and planning of the intensive programme.

The purpose of the consultation is that the nurse acquires a comprehensive sense of patients, including their current resources and needs, insight into the course of illness and treatment and motivation to change lifestyle in accordance with the recommendations. Patients are encouraged to describe their course of illness so far, and the nurse supports the patients in setting goals for both the short term and long term, depending on the current problems.

The initial consultation
The nurse uses patient records to determine patients’ diagnoses, risk factors, course of illness and treatment, planned examinations and tests and any pharmaceutical treatment and gets a sense of lifestyle and goals based on the other individual consultations.

An interview guide (available in Danish at www.CardiacRehabilitation.dk) ensures that the nurse achieves the agreed goals for the consultation. The guide is applied flexibly, since the consultation is based on patients’ needs.

Patients’ descriptions of the previous course of illness: Experience shows that patients and professionals can weight various aspects differently. Allowing patients to recount their course of illness gives the nurse a solid basis to understand patients, their course of illness and the subjective impressions experienced.

Patients’ descriptions of the situation since discharge or completion of treatment: The nurse asks about patients’ current physical, mental and social situation. How has it been to come home and start daily life again? How have family members reacted?

Patients’ physical, mental and social resources: The nurse mainly focuses on mental and social resources. The nurse asks about patients’ private life, work, networks (including contact with primary health care), leisure activities, experience with previous bouts of illness and mental well-being.

Patients’ health resources: Patients are encouraged to describe their strengths. What are they good at? How do they cope with adversity? Which characteristics do they use to cope? Most of these patients are not used to describing themselves and therefore need support in expressing their strengths.

Current physical, mental and social problems: The nurse helps patients in assessing their current physical, mental and social problems. Patients’ mental status is assessed in relation to the natural reaction to crises (in accordance with Cullberg’s (36) theory of the four phases of a crisis: shock, reaction, adaptation and reorientation), anxiety and depression.

Patients’ smoking history: Patients’ smoking habits are determined. The nurse asks smokers how many years they have smoked, their current consumption and whether they have tried to quit.

Patients’ motivation to carry out the recommended changes in lifestyle: Each patient enters into an agreement with the nurse on whether the patient will attempt to change several lifestyle facets at once or one at a time.

Goal-setting and initiatives: Patients are encouraged to formulate short-term and long-term goals for change based on the problems and their motivation to change their lifestyle. The goals are used to agree on an action plan, including any referral to psychiatrists, social workers and/or alcohol treatment professionals.

Patients’ expectations towards the rehabilitation programme: Patients are encouraged to describe their expectations towards the rehabilitation programme, and the nurse and patient discuss the potential to meet these expectations.

Patients’ follow-up by other hospital departments: To ensure optimum coordination, the nurse investigates whether other hospital departments are following up patients.

Patients’ wishes about family members participating: Patients are encouraged to ask their family members (especially spouses) to participate in the programme, but the clinical team respects the wishes of patients who want to participate alone.

Pharmaceutical treatment: The nurse reviews the current pharmaceutical treatment with patients. Can they tolerate the medicine? Do they remember to take it? Can they afford the co-payments?

Heart-health orientation binder: At the end of the consultation, the nurse gives the heart-health orientation binder, which contains relevant material, to the patients who did not receive it during admission. The nurse may also give patients other written material if they can benefit.

Need for follow-up consultation with the nurse: Follow-up consultation can be arranged if planned initiatives need to be coordinated and followed up or planned goals need to be evaluated, including any new goals and action plans. Follow-up consultation will further be relevant for patients motivated to participate in smoking cessation counselling or who need to have a family member attend a review of the programme. Patients referred to a psychiatrist or alcoholism treatment should have follow-up consultation with the nurse at which they can jointly assess the situation based on any new treatment initiatives.

4.2.6 Interprofessional conference

After the individual consultations, the weekly interprofessional conference discusses the patients. This conference is mandatory for all professionals involved, who prepare for the conference so that they can present patients’ cases, discuss based on the perspectives of each profession and determine the final goals of treatment.

The clinical team has joint interprofessional responsibility for conducting the conference at a professionally qualified level and within the established time frame. The project manager ensures that the meeting is held in relation to the agreed framework, and the secretary is responsible for preparing the list of patients so that the professionals can prepare. The nurse is responsible for presenting the patients and tying up loose ends. The other professionals are responsible for supplementing the discussion from their professional perspective.

The purpose of the interprofessional conference is to ensure that each patient has an interprofessionally coordinated and individually tailored rehabilitation programme and to determine the interprofessionally coordinated treatment goals adapted to each patient’s motivation and resources.

The conference
The conference takes 1 hour and is based on the joint electronic patient record for each patient. The conference has a standard agenda. The secretary records decisions made in the patient record.

The nurse reviews all new patients, summarizing their illness history and the state of diagnosis, assessment, prognosis and review of risk factors and current pharmaceutical treatment. Each patient’s psychosocial situation is summarized and resources and barriers are reviewed. The interprofessional treatment goals are adjusted based on the information available, and the final treatment plan is determined. Then specific problems among current patients are discussed. The problems are placed on the agenda before the conference takes place. The problems requiring interprofessional initiatives are presented briefly and discussed. The conference ends by reviewing and coordinating the work tasks of the coming week.


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