Terza fase della riabilitazione: sperimentazione di un modello gestionale "home-control" Third phase of cardiac rehabilitation: a nurse-based "home-control" model

Third phase of cardiac rehabilitation: a nurse-based "home-control" model. S. Albertini, A. Ciocca, C. Opasich, G.D. Pinna, F. Cobelli. Background. Phase 3 is a critical point for cardiac reha- bilitation: many problems don't allow achieving a correct secondary prevention, in particular regarding the relation- ship between patient and cardiologist. Aiming at ensuring continuity of care of phase 3 cardiac rehabilitation patients, we have developed a telemetric edu- cational program to stimulate in them the will and capacity to become active co-managers of their disease. Methods. Nurses specialized in cardiac rehabilitation, with the collaboration of the general practitioners, con- tact the patients by scheduled phone calls to collect ques- tionnaires about their health status and the result of bio- chemistry. All the results are analyzed by the nurses and discussed with each patient (educational reinforcement). The effects of this program of co-management of car- diac disease and secondary prevention are analyzed com- paring each patient data at the discharge with data after one year and those coming from our archive (retrospec- tive analysis). Results. The patients enrolled in this study pay much more attention to the amount of food they eat; they tend not to gain weight, and they restart smoking in a reduced pro- portion compared to patients not enrolled in the study. However, despite having received better information on their cardiac disease, their compliance to physical training, consumption of healthy food, and pharmacological therapy is not improved. Conclusions. This study focuses on the role of a contin- uous educational program of a cardiac rehabilitation unit after the patient's discharge. This home control program conducted by nurses spe- cialized in cardiac rehabilitation, with the assistance of car- diologists, psychologists and physiotherapists, and in collab- oration with the general practitioner, was quite cheap, and helped maximizing the knowledge of the disease and rein- forcing correct life style in the patients. The results are not as good as expected, probably be- cause one year does not represent a sufficient time, or because the educational intervention needs to be improved.