The Country Heart Attack Prevention (CHAP) Project: implementation of a four-step cardiac rehabilitation model of care for rural and remote patients in South Australia

The CHAP comprises a four-step model of care for cardiac rehabilitation (CR) that will be implemented in regional, remote and rural South Australia health services from 01/07/2021 to all adult (>=18 years) patients with acute myocardial infarction, hypertensive heart disease, ischemic heart disease, arrhythmias and heart failure regardless of their participation in this study. The steps, which will be developed and offered to participants in parallel and implemented into practice at least for the whole duration of the study (3 years), include: 1. An education program on CR co-designed with clinicians targeting all cardiologists, physicians, General Practitioners (GPs), nurses and allied health professionals working in regional, remote and rural South Australia. This program will be delivered through a website, web conferences and 3 two-hour workshops over 3 years (2020-2022), and will include themes related to lifestyle risk modification strategies, clinical management of risk factors, and CR referral and conduction. Education materials will be designed specifically for this study. Professionals will be asked to spend 45 minutes in online educational monthly sessions in a total of 11 sessions/year (there are no sessions in January). Professionals are recommended to use educational resources in the website according to their needs. 2. An automatic referral system across hospitals in regional, remote and rural South Australia that will identify eligible in-patients through DRGs and automatically refer them to a central telephone referral service by the Enterprise Patient Administrating System (EPAS). Additionally, a simple paper and fax-based referral system will be implemented to enable referrals to CR services by GPs working in primary care. This system will be available from 01/07/2021. 3. A web-based and a hybrid (face-to-face with the GP + telephone-based) modes of delivery of cardiac rehabilitation that, in addition to the existing ones (face-to-face and telephone-based), will be offered to all patients in regional, remote and rural South Australia from 01/07/2021. Patients will be able to choose among the modes of delivery according to their preferences. -For the web-delivered program: Participants will have a personal log-in to the website. As per the National Heart Foundation and Australian Cardiac Rehabilitation Association (ACRA) guidelines, all cardiac rehabilitation programs will be comprised of 10 modules (Initial Assessment and Goal Setting, Heart Education and Self-management, Exercise Training and Physical Activity, Healthy Eating and Weight management, Tobacco Cessation and Alcohol Reduction, Medication Education and Review, Managing Medical Risk Factors, Psychosocial Wellbeing, Activities of Daily Living, Reassessment and Completion) that will be complete over 6-10 weeks. Patients will be offered the modules according to their individual needs. The anticipated duration of each web module completion is 30 minutes/week. It will be required that those in the web-delivery model to read short texts, watch short videos (about 5/module), self-report their dietary, physical activity, smoking and alcohol ingestion habits weekly through responding online questionnaires on the website. They will also be asked to set their personal goals by completing an online table in the beginning of the program and to complete four Heart Health Assessments (at the beginning of the project, 8-12 weeks, 6 and 12 months post-discharge). The Heart Health Assessments will have an expected duration of 20 minutes and will be comprised of questionnaires that assess lifestyle habits, exercise capacity, quality of life, mental health (depression and anxiety). In addition, all patients will be offered a 6 and 12-month follow-up that will be performed by the GP. -For the hybrid program, Heart Health pre-assessment will occur at the beginning of the program (i.e. 1-2 weeks post-discharge) and will last 75 minutes (60 minutes with a Practice Nurse and 15 minutes with the GP). Re-assessments will occur 8-12 weeks, 6 months and 12 months post-discharge and will include 45 to 60 minutes consultations with the practice nurse, and 15-minute consultations with the GP. The CR program will be delivered by a nurse through telephone (10 modules, as per Heart Foundation and ACRA recommendations, of 30-minute duration over 6-10 weeks depending on the individual patient needs). 4-The quality of the programs will be assessed through an accreditation process of providers and programs based on the national key performance indicators established by ACRA and Heart Foundation. This accreditation process will be co-delivered in partnership with ACRA and the Department of Health of South Australia (SA Health) to all CR services in regional, remote and rural South Australia. The process will start from 01/07/2021.