Objective: A gap analysis undertaken by the South Australian Cardiology Clinical Network Prevention and Rehabilitation Workgroup identified no statewide coordinated rehabilitation pathways, limited active referral processes and no standardised data collection systems. A new cardiac rehabilitation model of care for patients following acute coronary syndrome/revascularisation hospitalisation was developed.
Methods: The project examined how cardiac rehabilitation can be developed into a clearly defined, systematic, coordinated approach across all health care sectors. The model was developed to reflect current health care services and align with future health care strategies at state and federal levels. Consultation with health care service planners, peak health care bodies and key clinicians was essential to developing it.
Results: Key to this new model is strengthening communication and referral systems between hospitals, rehabilitation services and primary health care to ensure seamless transition of care. Provision of in hospital cardiac education tools and a standard discharge resource allows patients to engage with cardiac rehabilitation principles. The model utilises a ‘community based’ Cardiac Rehabilitation Coordinator as a central point for patient engagement. Patient choice in delivery methods of ‘outpatient’ programs will create a more flexible system. Robust data collection reporting and evaluation systems underpin this model.
Conclusions: South Australia has a unique opportunity to implement an innovative cardiac rehabilitation system. The model is being further scoped and costed and an implementation plan developed.