Project Summary
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.
We 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.
If the feasibility trial is successful, we will proceed to conduct a parallel, 2-arm, single blind, multi-site
superiority RCT to compare the effectiveness and value (cost-effectiveness) of SC versus TAU (CBR) in older
frail adults living rural counties. Our long-term objective is to provide hospital systems with high quality
evidence on how best to optimize uptake of CR and PR for older frail adults living in rural communities.
