Perspectives of cardiac rehabilitation staff on strategies used to assess, monitor and review – a descriptive qualitative study

Background: The mechanisms contributing to the success of cardiac rehabilitation (CR) are poorly understood and may include assessment, monitoring and review activities enabled by continuity of care and this is investigated in this study. Objectives: To identify active assessment components of CR. Methods: A qualitative study using focus groups and individual interviews. CR staff (n = 39) were recruited via professional association email and network contacts and organised into major themes. Results: CR staff assessment strategies and timely actions undertaken provided a sophisticated post-discharge safety net for patients. Continuity of care enabled detection of adverse health indicators, of which medication issues were prominent. Interventions were timely and personalised and therefore likely to impact outcomes, but seldom documented or reported and thus invisible to audit. Conclusion: CR staff assessment and intervention activities provide an unrecognised safety net of activities enabled by continuity of care, potentially contributing to the effectiveness of CR.