Table 1 Overview of pre- and post-service design cardiac rehabilitation programme characteristics

Records and record keeping

Mainly paper-based records and minimal record keeping - difficult to share across CR teams

Web-enabled secure technology platform providing a standardised and integrated pathway covering:

• Patient identification and referral

• Referral management and patient recruitment

• Comprehensive assessment and personalised programme delivery

• Final assessment

• Discharge to long-term management

Interface with NACR

Duplication of data entry required for NACR, hospital systems and team records.

Enables uploads to NACR

Liaison between CR healthcare professionals

Informal, ad hoc and fragmented, with poor links with the heart failure team

Facilitates liaison between Cardiac Specialist Nurses and other healthcare professionals, including consultant cardiologists and General Practitioners

Integration of care with community services

Poor links between secondary care and community services

Provides integration between secondary care and community services

First assessments

Minimal first assessments carried out – done at first exercise session (including NACR Questionnaire 1)

Full initial assessment of eligible patients

Final assessments

No final assessments (other than NACR Questionnaire 2)

Full final assessment of eligible patients

Programme individualisation and goal setting

Minimal programme individualisation and goal setting

Provision of individualised programmes and goals for patients and management of patients throughout their CR programme

Educational sessions

Lacked consistency

Includes a full programme of exercise and educational sessions

Patient engagement initiatives

None

Includes patient/carer website allowing access to personalised care plan, progress, educational materials and an additional means of communication with the CR team. Included a patient focus group with feedback received from 122/350 participants.