When Covid-19 struck, health systems rapidly shifted certain in-person care models to virtual, home-based offerings to limit the spread of the coronavirus and maintain care continuity. One integrated health and social services network in Québec—Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Ouest-de-I'île-de-Montréal (CIUSSS West-Central Montréal)—was just seven months into operating its new regional cardiac rehabilitation program when health officials detected Covid-19 in Canada.
This program improves cardiac health and decreases chances of future heart problems after patients experience heart attack, heart failure, angioplasty, or heart surgery through exercise and education in addition to routine medical visits. CIUSSS West-Central Montréal's cardiac rehab has enrolled 254 patients overall since its inception.
Despite the program's infancy when Covid-19 was initially detected, CIUSSS West-Central Montréal's clinical coordinators were forced to rapidly restructure it to deliver those "holistic" elements virtually as well as in-person, preserving access in the process.
This new version is considered a "hybrid" model—patients have the option to meet with their clinicians through a mix of phone and video appointments, or to continue their weekly in-person appointments.
The model's 3 'hybrid' elements address medical, social concerns that affect cardiac health
What sets this model apart from other hybrid cardiac rehab programs is its dedication to addressing both medical and social factors that lead to poor cardiac health through hybrid delivery.
1. Motivational interviewing: Clinicians in this program use motivational interviewing to reflect patients' medical and social concerns back to them and establish an individualized care plan to address them. This form of interviewing empowers people to make changes in their lives by drawing out their own meaning, importance, and agency for change. Just as they would in person, clinicians maintained this form of dialogue with patients over virtual platforms to help address new fears and concerns brought on by Covid-19.
2. Live exercise sessions: In-person program participants still exercise in the program's clinic, but the kinesiologists on the care team organized home-based, live virtual exercise sessions as well. These sessions help to maintain a group environment, encourage camaraderie, and help patients maintain daily workout schedules. While participants typically finish cardiac rehab in 12-16 weeks, they can still access these live sessions after they complete the program. In this way, patients can stay in contact with each other, maintain their workout routines designed to meet their clinical needs, and can continue to hardwire these habits into the future.
3. Access to a multidisciplinary care team: The program's care team is composed of a wide variety of clinicians—kinesiologists, cardiologists, a nurse, a dietician, a psychologist, a social worker, a physiotherapist, and an occupational therapist—to provide guidance for all areas of a patient's life that could contribute to cardiac issues. For example, stress is a massive contributor to cardiac problems so having a psychologist and a social worker on the team to help patients address these issues brings long-term clinical benefit. Patients can now schedule virtual appointments with each clinician depending on their needs and specific care plans.
How we know the hybrid model is working—and what's in store for its future
While it's too early to quantitatively assess the shift to the hybrid program, two signs point to initial success:
1. Higher patient satisfaction: Even though the hybrid model's patients had to navigate the same telehealth-related hiccups that patients everywhere had at the onset of the pandemic, the participants report high levels of satisfaction with the program. Clinical coordinators shared that the virtual components of the program allowed patients to remain connected during the pandemic, thereby decreasing social isolation and potential stress that could contribute negatively to their cardiac health. Since most cardiac rehab participants are elderly, keeping them home, safe, and healthy during Covid-19 was pertinent.
2. Better participant adherence: 10 months into the hybrid program's existence, the clinical coordinators report that very few patients have withdrawn from the program prior to completion. They attribute this increased adherence to both having flexibility in care delivery and to the program's insistence on addressing patients' range of medical and social concerns.
The clinical coordinators developed an electronic referral system within the system's EMR which prompts the cardiologist at discharge to refer or not refer patients to cardiac rehab after specific diagnoses and care plans. This ensures that cardiologists consider cardiac rehab for all patients with similar diagnoses.
This new referral method went live on June 14th. As the program's main clinical coordinator told us, "Research supports home-based rehab models. This is something we're going to continue. This is the model of the future, to be able to reach out to as many people as possible."