Services can be delivered in a variety of ways in acute and non-acute health facilities, as well as at home. Modes of delivery are usually a combination of face to face individual or group encounters, telephone calls, video calls, telemonitoring and home visits. [#woodruffe-s-neubeck-l-clark-ra-et-al.-2015, #clark-ra-inglis-sc-mcalister-fa-et-al.-2007, #mcalister-fa-stewart-s-ferrua-s-et-al.-2004, #phillips-co-singa-rm-rubin-hr-et-al.-2005, #van-spall-hgc-rahman-t-mytton-o-et-al]
During the inpatient phase, multidisciplinary services should focus on:
- Practical support regarding clinical management and the hospital stay
- Support and education around risk modification, self management principles, resumption of activity, driving and return to work, as relevant to the individual
- Early discharge support
- Introduction and referral to post acute management and follow up
Post hospital discharge patients may be followed up in a range of settings. Home visits and disease management clinics have been found to be effective in reducing mortality in patients with heart failure. [#van-spall-hgc-rahman-t-mytton-o-et-al]
- Centre based approaches may include a variety of interactions from one on one clinic visits to comprehensive disease management programs.
- Individual consultations are useful for initial review post-discharge, initial assessment for exercise rehabilitation and for patients with complex needs, such as those requiring medication titration or psychological support
- Multidisciplinary rehabilitation programs conducted in hospitals or community settings should, where possible, include both exercise as well as education sessions. These are generally conducted as a group to provide patients with social interaction
- For exercise rehabilitation, the hospital setting is preferable for patients with: severe or unstable disease (including those awaiting heart transplant), complex co-morbidities and supplemental oxygen requirements
- Home-based support may be delivered by a variety of approaches including face-to-face home visits, telephone or video coaching, and computer or mobile phone programs and applications
- Home-based support can provide access to services for patients who are working, who experience transport difficulties or have severe deconditioning following an inpatient admission
- Interviewing patients at home helps identify issues such as expired, duplicated or medicines that have previously been stopped, as well as the storage conditions of medicines (e.g., GTN tablets). Over-the-counter complementary medications may also be more readily available for review in the home setting
Apps and other support tools
There are an increasing number of applications and online programs, wearable devices, and structured telephone and remote monitoring support services that can help patients to maintain motivation to make life-style changes and respond to changes in symptoms. The available technology is changing rapidly and ranges from main stream wearable devices, tailored text messaging services to maintain motivation through to telemonitoring of physiological parameters.