Stepped Care vs Center-based Cardiopulmonary Rehabilitation for Older Frail Adults Living in Rural MA

Cardiac rehabilitation (CR) decreases mortality and both CR and pulmonary rehabilitation (PR) improve function, quality of life, and decrease readmission rates. Despite their proven efficacy, both programs are grossly underutilized, with fewer than 20% of eligible persons participating. Patients with heart and lung disease living in rural communities have even lower rates of participation.

The objective of this proposal is to test the feasibility of performing a full-scale randomized controlled trial (RCT) to compare the effectiveness and value of a stepped care (SC) model versus treatment as usual (TAU) in older frail adults living rural counties. TAU refers to center-based rehabilitation (CBR). The SC model includes initial enrollment into CBR followed by possible step up to three interventions based on prespecified non-response criteria: 1) Transportation-subsidized CBR, 2) Home-based telerehabilitation (TR), and 3) Community health worker-(CHW) supported home-based TR. Unlike traditional SC models, the initial treatment in this model, i.e. CBR, is not the least resource intensive. CBR was chosen as the initial option because it is currently considered the standard of care.

The investigators will conduct a parallel, 2-arm, randomized controlled feasibility trial. Eligible participants will be randomized to TAU (CBR) or SC. Because of the urgent need to address underuse of both CR and PR in rural regions, the proposed feasibility trial will enroll patients referred to either CR or PR. Both arms include an in-person intake evaluation conducted by a certified rehabilitation nurse in the rehabilitation center to determine exercise tolerance and design a tailored 8-week rehabilitation program. Patients randomized to TAU participate in two weekly sessions at the center and are encouraged to exercise at home in between sessions. Patients randomized to the SC arm will also be enrolled in the CBR program. Those who meet prespecified non-response criteria will be stepped up to transportation-subsidized CBR. Providing transportation may not be sufficient for frail older adults who are reluctant to leave their homes in the winter, unfamiliar with exercising, or do not want to exercise in a group setting. Thus, non-responders, will be stepped up to home-based TR. Home-based rehabilitation will be supported by Chanl Health, a virtual platform that supports education and self-management, remote monitoring, and coaching by rehabilitation specialists. Non-responders will be stepped up to CHW-supported home-based TR. The CHW will be help participants use the mobile app, access educational materials, clarify educational content, and exercise during biweekly in-person visits.

Purpose: Heart and lung disease are the first and third leading causes of mortality in the US, respectively. Cardiac rehabilitation (CR) decreases mortality and both CR and pulmonary rehabilitation (PR) improve function, quality of life, and decrease readmission rates. Despite their proven efficacy, both programs are grossly underutilized, with fewer than 20% of eligible persons participating. Patients living in rural communities have even lower rates of participation. Home-based CR and PR has been developed with the goal of improving uptake, and low to moderate strength evidence indicates that these programs are as effective as center-based programs. Further work is needed, however, to examine how best to increase utilization of CR and PR in rural communities. While several studies have examined approaches to improve referral and enrollment, there is little evidence on how to optimize adherence to CR, and no evidence how to optimize adherence to PR.

Inclusion criteria

• Older adults (greater than 60 years of age)
• Live in a Level 1 or 2 state designated rural area in Berkshire County
• Has a condition qualifying for reimbursement (by government or private insurance) for cardiac or pulmonary rehabilitation
• Score of 4, 5 or 6 on the Clinical Frailty Scale(24) (corresponding to vulnerable, mildly frail, and moderately frail)

Exclusion criteria

Attended pulmonary or cardiac rehabilitation within the previous two years

• Resting pulse oximetry < 85% on room air or while breathing the prescribed level of supplemental oxygen
• Unstable asthma with hospital admission or ED visit within previous three months
• Severe exercise-induced hypoxemia, not correctable with oxygen supplementation
• Acute systemic illness or fever
• Complex ventricular arrhythmias
• Resting systolic blood pressure greater than 200mmhg
• Resting diastolic blood pressure greater than 100mmhg
• Orthostatic blood pressure (BP) drop of >20 mm Hg with symptoms
• History of arrhythmia with syncope
• Severe symptomatic valvular disease
• Unstable angina
• Uncontrolled atrial or ventricular arrhythmias
• Uncontrolled sinus tachycardia (>120 BPM)
• Uncompensated congestive heart failure
• Third degree heart block without a pacemaker
• Active pericarditis or myocarditis
• Acute cor pulmonale, severe pulmonary hypertension
• Resting ST displacement > 2mm
• Uncontrolled diabetes (resting blood glucose >400 mg/dl)
• Conditions other than pulmonary or cardiac that prohibit exercise (e.g., arthritis, severe neurologic, hepatic or renal disease)
• Planned surgery or transplantation
• Hearing impairment limiting ability to participate in data collection by telephone
• Life expectancy less than one year
• Significant cognitive deficit and/or psychiatric illness that interferes with ability to provide consent, follow directions, or adhere to study procedures
• referral to cardiac rehab after coronary artery bypass graph (CABG) and valvular surgery