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The Heart Manual – Coronary Artery Disease Edition (4th Ed)

For many years users have asked for ‘one’ Heart Manual, which could be used with all cardiac patients. This was reiterated by a further study in the UK conducted by the HM (2004)

Following a successful funding application to the British Heart Foundation in December 2006, the Heart Manual has been comprehensively revised. This new edition of the Manual is now available and is suitable for most patients who have had:

What is it?

The Heart Manual is a cognitive behavioural chronic disease management programme for people with coronary heart disease produced by NHS Lothian

It is an individualised and menu-based programme. A patient’s needs are determined by an initial assessment process which covers the usual medical targets such as lifestyle change and adherence to prescribed medications with further reviews at agreed intervals

It attends to the patient's beliefs about the illness, helping to change damaging beliefs to more helpful ones.  Unhelpful beliefs can lead to unhelpful coping actions such as the ‘over activity-rest trap’.  Working with healthcare staff, patients are helped to identify and change these behaviours. Common psychological reactions to the diagnosis or to an acute event are explained and self-management or appropriate referral to expert help is implemented. In this way the Heart Manual has been shown to reduce unnecessary disability and improve patients’ quality of life. Research has shown that in this way the Heart Manual can dramatically improve psychological outcome and lower health costs through reducing unplanned admissions to care.

What is different about the 4th edition?

There is increased focus on additional self-management techniques which have proved useful over the last fifteen years, e.g. goal-setting, and new knowledge about reactions to chronic illness.  In this 4th edition there will be fewer words and more pictures, making it suitable for more patients.

The modified version was primarily developed for the heart foundation in New Zealand in early 2007 and is currently being evaluated in a major 2 year study with 600 patients over 6 sites. Their study is primarily assessing uptake and completion of the programme and secondly measuring clinical outcomes at defined intervals. Interim results have been very positive.

What are the patient held materials?

One of the most obvious modifications has been to ‘divide’ the 1 manual into 3 booklets/parts, a separate diary , a relaxation CD and a CD rom showing animated graphics on CHD conditions.

Part 1 (39 pages) containing the ‘core pages with information’ which all patients should read
Contents are:

Part 2 (91 pages) the patient and the facilitator choose from the contents list the pages applicable to the individual patient
A selection from the list are

Part 3 (13 pages) Partner and family information

Heart Manual Diary - record and goal/target sheets.

A Relaxation CD or audio tape

An information CD

NB: Parts of the information CD could also be used with the patient in the initial meeting to show them how the heart works

How is it used?

It will continue to be delivered by a Facilitator, who is specially trained on a two day programme which covers the psychological manifestations of CHD, behavioural interventions to aid reduction in symptoms, risk factor management, medications, etc.

The programme is delivered through a series of contacts with the patient and wherever possible their partner, carer or family.  These contacts could be a combination of an: individual’s home; a group setting where there is protected time for one-to-one input; a hospital setting; in a community centre, GP practice or by telephone, etc i.e. whatever is appropriate to the resources, capacity and patient in a given area.

Following the assessment and joint goal setting, the patient and, where desired, their partner and family, move towards their goals for a new lifestyle in small easily achieved steps.

What resource does it require?

The main resource implications are the time of the facilitator and the cost of the materials.  The facilitator costs are based on the number of contacts, the grade of the staff and the method for making contact (phone, clinic or home visit, travel time).

The length of the programme is not fixed and ideally the programme would continue until all of the agreed goals for a new lifestyle have been achieved and it has been demonstrated that the patient will continue with their new lifestyle.  However, limitations in resources will usually mean that a local protocol for a maximum number of contacts is required. It would be prudent when establishing the programme in areas to clearly define how goals achieved by patients would be monitored and by whom, to ensure maintained change, and in turn long-term effectiveness.

How many patient contacts are required?

The minimum is an initial face-to-face meeting, followed by a brief contact to review and increase goals at one, two, four and twelve weeks. Patients who are doing well and have few problems may need less intensive contact, saving time for more intensive work with patients who are struggling or perhaps have co-morbidities.

What are the facilitator materials and what training to they receive?

The facilitator must be trained and issued with a practising certificate.
They will receive, along with what the patient gets-a comprehensive training folder (contains the two day training course material);

Existing / registered facilitators

The ‘crossover’ training will be provided free of charge to all existing facilitators on the current database, (whose areas wish to utilise the new programme) and will be delivered by both paper and electronic format. They will also receive, along with what the patient gets, a comprehensive training folder (contains the two day training course material);

Content of training days includes the following:

DAY 1 and 2

A register of trained facilitators is maintained by the Heart Manual Department, Astley Ainslie Hospital, NHS Lothian and care is taken that the patient materials are not issued to non-registered facilitators.

How much does it cost to provide the programme for patients?

Despite the wealth of information contained in the training folders, it is not envisaged increasing the cost of training to purchasers over and above the annual cost-of living increase. The same applies to the patient programme, where the cost will remain the same apart from the annual cost of living increase.

The cost of facilitator time will vary widely according to grade of staff involved and the service delivery model adopted in any area.  An example of how these models have been costed in the UK for an early version of the Heart Manual can be obtained from the Heart Manual Office.

What are the benefits to the patient of providing the programme?

The expected benefits from previous studies using the same methods and similar materials are the same as from hospital-based rehabilitation; these include a 26% reduction in the risk of cardiac death in the next 2-5 years, improved lifestyle, a reduction in anxiety and depression, improved quality of life and reduction in re-admissions to hospital. Most importantly the patient is enabled to become an active manager of their own health – an ‘expert patient’.

As aforementioned the original manual has gathered much evidence to date, however it would be prudent of us to lead on a strategy for piloting and evaluating the new model and to share that research design with service users keen to use the product.

What are the benefits to the health service of providing the programme?

The need to help people become active managers of their own health is now widely acknowledged. Patients who become more active managers report less distress, fewer symptoms and are seen in primary and secondary care less often. In practical terms this 4th edition complements the government’s long- term management agenda on chronic disease, notably CHD and its related conditions.

Note: In order to ensure transition, sustainability, user and patient choice, the Heart Manual (MI and Revascularisation 2007 editions) will continue to be offered alongside the 4th edition.

For further information please contact us as below:

The Heart Manual Department 
Astley Ainslie Hospital;
133 Grange Loan
Edinburgh EH9 2HL

Tel: 0131 537 9127/9137
E-mail:  heart.manual@nhslothian.scot.nhs.uk

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