Heart2Heart: An Integrated Approach To Cardiac .
Research and DevelopmentHeart2Heart: An integratedapproach to cardiacrehabilitation and CBTMarion Elliot Cardiology Liaison Advanced Nurse Practitioner, Oxford University Hospitals NHS Trust;Heather Salt Consultant Clinical Health Psychologist, June Dent Consultant Clinical Psychologist, ClareStafford Programme Manager, Community Services Division and Angeliki Schiza Assistant Psychologist,Oxford Health NHS Foundation Trust Email: Marion.Elliot@ouh.nhs.uk 2014 MA Healthcare LtdAnxiety and depression are up to three times higherin people with cardiac conditions (Lane et al,2002). Major depression was identified in 19.8% ofsurvivors of acute myocardial infarction (MI) (Thombset al, 2006), while in a meta-analysis of patients withchronic heart failure, anxiety was identified in 11–45% ofpatients and depression in 10–60% of patients (Yohanneset al, 2010). Anxiety and depression are associated withlower levels of self-efficacy, impaired health status, andpoor treatment compliance and outcomes. This canincrease risk and repeated attendance to patients’ GPs oraccident and emergency departments (Grace et al, 2004;Thombs et al, 2006). Psychological difficulties have alsobeen associated with reduced self-care and attendance atcardiac rehabilitation and increased use of medicalservices (Strik et al, 2003; Lane et al, 2001). Anxiety anddepression have both been related to increasedcardiovascular morbidity and mortality (Frasure-Smithet al, 2000).The National Institute for Health and Care Excellence(NICE) (2011a) identified evidence that people withlong-term physical health conditions, such as diabetesand cardiovascular disease, often have a comorbid mentalhealth condition. However, studies have shown thatthese mental health needs are not always met. Forexample, Knapp et al (2011) reported that around430 000 people who had depression as well as diabetes—asignificant risk factor for cardiovascular disease—received sub-optimal care.There is also evidence that psychological interventionshave positive outcomes for cardiac patients. Forexample, in a Cochrane meta-analysis, Whalley et al(2011) found that psychological treatments producesmall-to-moderate reductions in depression and anxietyand can reduce cardiac mortality in patients withcoronary heart disease. However, they did not find anyevidence that psychological interventions reduced rateof heart attack or need for cardiac surgery, or totalmortality. Positive impact was also found by O’Neil et al(2011) in a meta-analysis of five randomised controlledBritish Journal of Cardiac NursingOctober 2014Vol 9 No 10 AbstractBackground: Heart2Heart is a service that integrates cardiacrehabilitation and psychological therapy for patients followingmyocardial infarction, as well as for those with other cardiacdiseases such as heart failure, cardiomyopathy and arrhythmias.Psychosocial support within cardiac rehabilitation programmes hastypically been delivered by a specialist psychologist embeddedwithin the cardiac rehabilitation team. Heart2Heart has providedan alternative to this model by developing a more extensiveservice, which includes primary and secondary care psychologicaltherapists working in a stepped-care way using the ImprovingAccess to Psychological Therapies (IAPT) stepped-care approach.Stepped care is the provision of the simplest care possible toachieve the intended aims. The service was one of 15 Departmentof Health long-term condition pathfinder sites evaluating thefeasibility of such a service and was subject to a nationalevaluation. Objectives: To provide an acceptable and accessiblepsychological assessment and treatment service to patients aspart of integrated cardiac care. Methods: This project wasdesigned as a feasibility study to develop an innovative serviceacross organisational boundaries. A selection of validated toolswas used to measure anxiety, depression and quality of lifeoutcomes. An economic analysis of primary and secondary careservice use was also carried out. Conclusions: The projectprovided timely and cost-effective cognitive behavioural therapywith high levels of patient satisfaction. Preliminary evidencesuggests clinically significant improvements in levels of anxiety,depression and quality of life. Further work is ongoing to explorethe economic impact on reducing hospital use and GP attendance.Key wordsw Cardiac w Anxiety w Depression w Cognitive behavioural therapyw Stepped care w IntegrationSubmitted for peer review: 10 April 2014. Accepted for publication: 4 August2014. Conflict of interest: This work has been supported by the Department ofHealth Improving Access to Psychological Therapies (IAPT) Long-Term Conditionsand Medically Unexplained Symptoms Pathfinder project501Downloaded from magonlinelibrary.com by 086.188.150.011 on October 10, 2019.
Research and Development502 Heart2Heart provides an alternative to this model, bycreating a more extensive service, following theImproving Access to Psychological Therapies (IAPT)model (Clark, 2011). IAPT is a national programmewhich was developed following a white papercommitment entitled Our Health, Our Care, Our Say(Department of Health (DH), 2006). IAPT aims toimprove access to evidence-based psychologicaltherapies for anxiety and depression and make themreadily available to the larger public. IAPT is structuredaround a model of stepped care, whereby the leastintensive intervention appropriate for an individual isprovided in the first instance. If patients require moreor less intensive input, they can then be stepped up ordown the pathway according to changing needs andtreatment response (Figure 1).Heart2Heart serviceThe Heart2Heart service has encompassed the IAPTstepped-care model, creating a robust psychologicalservice integrated with the cardiac specialist services.This service development encompassed a collaborativemulti-agency approach, working across organisationalboundaries between secondary care cardiac rehabilitation,secondary care clinical health psychology and primarymental healthcare through the local IAPT service.Collaborating with IAPT has enabled the service tospread out across various locations in Oxfordshire, asIAPT sees patients across multiple GP surgeries in thecounty. It has also enabled the service to operate bydeveloping the skills of IAPT staff who have been trainedin providing CBT to people with long-term physicalconditions, thus increasing service capacity through alarge number of available therapists.The Heart2Heart service has been developed andreceived funding as one of the 15 Department of HealthLong Term Conditions Pathfinder sites (Lusignan et al,2013), enabling the service to be evaluated nationally aswell as locally. It has been developed as a feasibility studyto evaluate the effectiveness of an integrated stepped-careapproach for cardiac patients. Working with colleaguesfrom existing services, through a service level agreement(SLA), a collaborative multi-agency partnership has beendeveloped to include representatives and clinicians fromprimary and secondary care and from physical andpsychological health services.Service designHeart2Heart involves four steps of care, with step 1being the least intensive and simplest intervention, andstep 4 as the most intensive intervention for the mostcomplex patients with severe presentations. Themovement of people from a step 1 intervention throughto a higher step intervention is based on increased needand on poor response to treatment at an earlier step.The aim is that the pathway of care is individualisedand appropriate to the patient. The service design isshown in Figure 2.British Journal of Cardiac NursingOctober 2014Vol 9 No 10Downloaded from magonlinelibrary.com by 086.188.150.011 on October 10, 2019. 2014 MA Healthcare Ltdtrials (RCTs). They found that depression treatmentinvolving pharmaceuticals and/or psychotherapy inpatients who had post-MI depression had a significanteffect on mental health quality of life and a modest butsignificant effect on physical health quality of life. Theabove body of research has led to psychologicalinterventions being advocated in key nationalguidelines. The NICE (2013) guidance for secondaryprevention of MI recommends that guidelines relatedto depression and anxiety (NICE, 2009a; 2009b; 2011a)are also consulted for management of patients who alsohave clinical anxiety or depression.Cardiac rehabilitation has increasingly incorporatedthese recommendations by including the screening ofcardiac patients for anxiety and depression and theinclusion of psychological interventions. Research hasshown that including psychological interventions incardiac rehabilitation can improve cardiac patients’adherence to lifestyle and medication regimens, reducemedical risk, and help them return to pre-morbid levels ofpsychosocial functioning and quality of life, to a greaterextent than cardiac rehabilitation without psychologicalcare (Linden et al, 1996; Dusseldorp et al, 1999).Psychological interventions for cardiac patients aremost commonly provided by a single psychologist attachedto a cardiac rehabilitation team. For example, the cardiacrehabilitation team at Guy’s and St Thomas’ NHSFoundation Trust developed an integrated stepped-careservice where a psychologist was embedded within theteam to provide physical and psychological assessmentand intervention (Child et al, 2010). Depending onsymptom severity and needs, the service encompassedpsychoeducational sessions, group workshops, briefindividual therapy, or longer-term individual therapyusing cognitive behavioural therapy (CBT) (Child et al,2010). This model was found to increase acceptability andaccessibility of psychological care by reducing stigma,bringing a significant increase in the number of patientsaccessing mental health care, with 50% of patientsaccepting psychology referrals compared with20% accepting referrals to liaison psychiatry (Child et al,2010). Before Heart2Heart, a similar service existed inOxfordshire which embedded a single psychologist in thecardiac rehabilitation team, providing assessment, grouppsychoeducation and individual CBT interventions(Sanders et al, 2011).The model of care in these services relies on referral toa single psychologist attached to the cardiac rehabilitationteam. Although evaluations of such services show thatpsychological care is made more accessible andacceptable, the model accommodates a relatively smallnumber of patients as only one member of staff canprovide psychological input. Employing a highly skilledclinician, such as a clinical or counselling psychologist,to provide services to people with low-to-moderatelevels of distress and complexity can also mean thatservices are paying a high cost for service provision to asmall number of patients.
Research and DevelopmentThe stepped-care modelThe recommendations in this guideline are presented within a stepped-care framework that aims to match the needsof people with depression to the most appropriate services, depending on the characteristics of their illness andtheir personal and social circumstances. Each step represents increased complexity of intervention, with highersteps assuming interventions in previous stepsStep 1: Recognition in primary care and general hospital settingsStep 2: Treatment of mild depression in primary careStep 3: Treatment of moderate-to-severe depression in primary careStep 4: Treatment of depression by mental health specialistsSteph 5: Inpatient treatment for depressionWho is responsible for care?Step 5: Inpatient care,crisis teamsWhat is the focus?What do they do?Risk to life, severeself-neglectMedication, combinedtreatments, ECTTreatment-resistant,recurrent, atypical andpsychotic depression, andthose at significant riskStep 4: Mental healthspecialists, includingcrisis teamsStep 3: Primary care team,primary care mental health workerStep 2: Primary care team,primary care mental health workerModerate orsevere depressionMild depressionStep 1: GP, practice nurseRecognitionMedication, complexpsychological interventions,combined treatmentsMedication, psychologicalinterventions, social supportWatchful waiting, guided self-help, computerisedcognitive behavioural therapy, exercise,brief psychological interventionsAssessmentFigure 1. Stepped-care model for the treatment of depression (Care Services Improvement Partnership and NationalInstitute for Mental Health in England, 2011)The Heart2Heart pathway includes:ww Step 1: A 1-hour CBT psychoeducation session embeddedwithin the cardiac rehabilitation programme. Routinescreening for anxiety and depression by the cardiacnurses using the Hospital Anxiety and Depression Scale(HADS) questionnaire (Zigmond and Snaith, 1983)wwSteps 2, 3 and 4: Psychological therapy for patientsand their carers. Step 2 therapy is provided bypsychological wellbeing practitioners (PWPs), step 3is provided by CBT therapists, and step 4 is providedby clinical health psychologists. 2014 MA Healthcare LtdParticipantsPatients referred to Heart2Heart have a variety of cardiacdiagnoses including MI, arrhythmias, heart failure andpeople who have undergone cardiac surgery or haveimplantable devices.Examples of psychological difficulties the cardiacpatients referred to Heart2Heart face include: healthanxiety; panic attacks; low mood due to loss of goodhealth and previous identity/role; avoidance of activities/British Journal of Cardiac NursingOctober 2014Vol 9 No 10 places they have associated with the cardiac event; fear ofgoing out on their own or driving in case they become ill;shock and denial about their cardiac diagnosis; traumafrom implantable cardioverter defibrillator (ICD) shocks;sleeping problems due to fear of dying in their sleep; andthe re-emergence of pre-morbid psychological issues.Heart2Heart can also be offered to and attended bycarers. The unmet psychological needs of carers wereinitially identified when carers were encouraged to beinvolved in the cardiac rehabilitation programme,particularly to attend patient appointments and the groupeducation sessions. Carers often highlighted that theyexperienced high levels of anxiety relating to the patients’cardiac event and might have been traumatised by seeingtheir relative have an MI or cardiac arrest. Unmet carerneed has been identified by several studies. Schulz et al(1995) reviewed a number of studies which found that overone-third of people who provide care for a relative withdementia suffer from high levels of depression, stress andgeneral psychological morbidity. They also report poorerphysical health and take more prescribed medication than503Downloaded from magonlinelibrary.com by 086.188.150.011 on October 10, 2019.
Research and DevelopmentSTEP 1ww Cardiac specialistnurses, exercisephysiologists, GPs,self-referralsww Routine screening foranxiety/depressionww Cognitive behaviouraltherapy (CBT) psychoeducation sessionembedded in cardiacrehabilitation programmeSTEP 2STEP 3ww Improving Access toPsychological Therapies(IAPT) service,psychological wellbeingpractitioner (PWP)ww Guided self-help forpatients and carersww Face-to-face/group/telephone work withpeople with mild-moderateanxiety/depressionww Computerised CBTww IAPT service,high-intensityCBT therapistww 1:1 CBT for patientsand carers who havemoderate–severedepression/anxiety orhave not responded totreatment at Step 2ww Long-term conditionsmindfulness classClinical supervisionof steps 1, 2, 3and 4 by step 4clinical healthpsychologistSTEP 4ww Clinical healthpsychologistww Assessment andIntervention for severeand complex casesand for those whohave not responded totreatment at Steps 2and 3Figure 2. The Heart2Heart model: Stepped care for individuals with cardiac disease and their carersOutcome measures and assessmentsOutcome measures are routinely collected and are anintegral part of the service evaluation in order toidentify whether this model of care is cost-effective andshould be replicated to other service providers.Outcome measures include:ww Using HADS (Zigmond and Snaith, 1983) to measurelevels of anxiety and depression. This is administered atthe beginning and end of therapyww The IAPT Minimum Dataset, which includes theGeneralised Anxiety Questionnaire (GAD 7) (Spitzer etal, 2006) to measure anxiety, the Patient HealthQuestionnaire (PHQ9) (Kroenke et al, 2001) to measuredepression, and the Work and Social Adjustment Scale(Mundt et al, 2002) to measure the impact of thepatient’s psychological difficulties on work and socialrelationships. These are administered at the beginningof every sessionww Quality of life outcomes are measured only at the initialand last therapy session using the Dartmouth Co-op(Wasson et al, 1992), the Minnesota Living with HeartFailure Questionnaire (MLWHFQ) (Rector et al, 1993) andthe EQ5D (EuroQuol Group, 1990)ww Measurement of patient experience (Steine et al, 2001)and the Clinical Global Impression Scale (Guy, 1976)collected at the end of therapy504 ww Primary and secondary healthcare use data on emergencydepartment attendances, inpatient admissions, outpatientappointments and GP consultations. These data areanalysed to see whether there is a reduction in health-carecosts and are collected for the 6 months before the start oftherapy and the 6 months after the end of therapy.ReferralsReferrals can be made using a number of sources. Thevarious nursing teams involved in cardiac care make themajority of referrals, as they provide the initial screeningfor anxiety or depression. Such nursing teams include thesecondary care cardiac rehabilitation service, arrhythmiaand ICD services, genetics and community heart failurespecialist nurses. Referrals for psychological interventioncan be made at any time during the patient’s journey asthey can express feelings of anxiety or depression at anytime. Initial screening assessments used by the nursingteams are HADS, Dartmouth Co-op and the MLWHFQ.In line with the IAPT ethos, patients and carers can alsoself-refer or be referred by their GP. It would be importantfor anyone wanting to replicate this service to connectwith their local IAPT and clinical health psychologyservices to establish how referrals can be made locally.Psychological therapists also need to link with their localcardiac specialist clinicians and the patient’s GP as allpatients seen in the service require medical monitoring.The information that needs to be provided to thepsychological therapist, for referrals made by cardiac nurses,includes cardiac diagnosis, medications, comorbidities,history of previous mental health problems, and questionnairescores from the HADS, the Dartmouth Co-op and theBritish Journal of Cardiac NursingOctober 2014Vol 9 No 10Downloaded from magonlinelibrary.com by 086.188.150.011 on October 10, 2019. 2014 MA Healthcare Ltdage-matched samples. NICE (2013) identifies limitedevidence (based on three studies of married couples) thatinvolving spouses may have beneficial effects on familyanxiety. As a result, carers are included and, whereappropriate, are offered psychological interventions.
Research and DevelopmentMLWHFQ. For patients who self-refer, the HADS, DartmouthCo-op and MLWHFQ measures are obtained by the therapistand a report on the medical condition can be obtained fromthe cardiac nurse, consultant or GP.All referrals are triaged by a step 4 clinical healthpsychologist and the patient is then assigned to the relevantstep and therapist in their local area. The psychologicaltherapist aims to contact the individual within a week ofreceiving the referral and assess them within a month fromreferral. Some patients who live out of area may prefer to beseen locally or opt for telephone work. Information fromthe initial assessment is shared, provided the patientconsents, with their cardiac nurse, cardiologist, GP or otherhealth professional as appropriate.Cognitive behavioural therapyThe psychological treatment of choice at all steps of care isCBT, which is recommended by NICE for the treatment ofmany anxiety disorders and depression (NICE, 2009a;2011b). CBT is a talking therapy which looks at the linksbetween thoughts, feelings, behaviours and bodilysensations. Its premise is that the way we interpret or thinkabout a situation makes us feel and behave in a certainway. In turn, the way we behave can have an effect on ourthoughts and feelings, thus creating a vicious cycle(Greenberger et al, 1995). Figure 3 shows the interactionbetween these areas, which is called the cognitive cycle.CBT aims to help people break ‘vicious’ cognitive cyclesthrough a range of techniques that address unhelpfulthinking patterns and unhelpful behaviours (Greenbergeret al, 1995). Treatment goals are agreed collaborativelybetween the therapist and the patient and an individualisedtreatment plan is formulated at the first appointment. 2014 MA Healthcare LtdStep 1 interventionStep 1 involves the routine screening for anxiety anddepression delivered by the cardiac nurses, as well as a CBTpsychoeducation session facilitated by a PWP. The psychoeducation sessions take place every few weeks so that eachpatient can attend once and they are offered in hospital orcommunity settings, such as leisure centres. The format ofthese sessions is relatively informal and covers thepsychological and emotional impacts of a cardiac event. Eachsession includes information on: common psychologicalreactions to cardiac events; the normal adjustment process tochanges in health; how to recognise problems adjusting; howto build confidence following a cardiac event; symptoms ofanxiety and how to distinguish these from cardiac problems;techniques to overcome anxiety; symptoms and treatment ofdepression; how to recognise symptoms; and when and howto seek help, including self-referral. These sessions alsoprovide an opportunity for patients and carers to discuss theirconcerns, learn about the service and discuss possibilities fora referral with their cardiac nurse.therapist to assess suitability for the service and whether thatstep of care is the most appropriate for the patient’s needs andlevel of severity. At step 2, the assessment is conducted face toface or on the phone, over a 45-minute session. At steps 3 and4, it is conducted in a face-to-face 1-hour session. If thepatient is appropriate for that step of care, a treatment plan isestablished. If the patient is not appropriate, they are steppedup or down or alternatively referred to another service.Alternative services where patients are referred are mostcommonly bereavement and counselling services.Step 2 interventionStep 2 is a low-intensity intervention provided by a PWP forindividuals who have mild-to-moderate anxiety ordepression. The majority of patients are seen at this step.After the initial assessment, subsequent sessions areconducted over the phone and last for 30 minutes. The totalnumber of sessions available at this step is 6 and if patientshave not recovered by the end of therapy, they may need tobe stepped up or signposted to a different service. The maintreatment mode at this step involves the provision ofpsychoeducation and behavioural activation through selfhelp material and telephone appointments. Other treatmentmodes available at step 2 which are less commonly followedare computerised CBT and group CBT for insomnia.Step 3 interventionStep 3 is a high-intensity intervention aimed at peoplewith moderate-to-severe anxiety and depression. Peoplemay be referred directly to step 3 from triage, if theyhaven’t responded to a step 2 intervention or if they havebeen stepped down from step 4. Step 3 interventions areprovided by CBT therapists and are normally up to20 face-to-face sessions which each last 1 hour. These areheld at the cardiac rehabilitation department, local GPsurgeries or the patient’s home if required by houseboundpatients, therefore having no impact on hospital space.Mindfulness-based CBT classes are also offered.Step 4 interventionStep 4 is for those people who present with the most severeforms of anxiety, depression and other sPhysical sensationsPsychological assessment at steps 2, 3 and 4Whichever step a patient is assessed at includes an initialassessment and a thorough risk assessment by the assignedBritish Journal of Cardiac NursingOctober 2014Vol 9 No 10 Figure 3. The five areas model (Greenberger et al, 1995)505Downloaded from magonlinelibrary.com by 086.188.150.011 on October 10, 2019.
Research and DevelopmentThree-month review of treatmentAll therapists offer a 3-month follow-up review and repeatmeasures of mood, anxiety and quality of life. The therapistwrites a discharge letter to the individual with a copy to hisor her GP, cardiac nurse, cardiologist and otherprofessionals involved in their care to maintain goodcommunication between parties.Clinical supervisionClinical supervision is an essential component in thepractice of talking therapies, including CBT, as it helpsdevelop the therapist’s clinical skills and reflection, as well asproviding a containing space to deal with the emotionalimpact of their work (Pretorius, 2006). In Heart2Heart,clinical supervision is provided by a step 4 clinical healthpsychologist, both to the various IAPT therapists, as well asto the cardiac nurses. For nurses, supervision takes place insmall groups of 3–4 nurses and exercise physiologists in thehospitals where they work, thus providing an accessiblespace to learn basic CBT techniques that aim to help themrecognise and manage anxiety and low mood in patients.OutcomesThe Heart2Heart project has identified and developed acollaborative stepped-care model of providing CBTbased interventions to the wider patient population inOxfordshire. This project embraces an alliance betweensecondary and primary care health professionals workingtogether in order to provide seamless care to patients andtheir carers, thus facilitating patient, family andcommunity integration of care. By offering theopportunity for early intervention it may reduce thepossibility of problems escalating.The outcome measures are being evaluated and earlyevidence indicates that the stepped-care interventions areeffective in reducing levels of anxiety and depression andimproving quality of life for people post MI and for peopleKey Pointsww Anxiety and depression are up to three times higher in people withcardiac diseaseww Heart2Heart integrates psychological and physical health servicesfor cardiac patients using a stepped-care modelww Stepped care provides the simplest care at first instance, providing acost-effective use of servicesww Using the Improving Access to Psychological Therapies (IAPT)workforce, the service provided cognitive behavioural therapy in arange of locations, allowing for a larger number of patients to beseen within a short period from referral506 with other cardiac conditions such as heart failure. Aneconomic evaluation of the service has also been initiatedand is analysing data on the number of patient contactswith their GP, the emergency department, and hospitalinpatient and outpatient visits. Preliminary data indicatesa reduction in emergency department and inpatient visits.Over a period of 29 months, between February 2012 andJuly 2014, 222 patients were referred to the service. Of the189 who attended an initial assessment, 146 attended atleast two therapy sessions. Sixty-six per cent of the peoplereferred had experienced a recent MI, whereas the rest hadheart failure or other heart disease. Detailed outcomemeasures will be reported in a later paper. As the servicewas developed as a DH pathfinder, the outcomes and theeconomic evaluation of the Heart2Heart project will alsobe reported to and analysed together with other pathfindersby the DH IAPT Long-Term Conditions and MedicallyUnexplained Symptoms Pathfinder projects team and willbe published separately.The main strengths of this project include timely andcost-efficient accessibility via local service provision,telephone or computer interventions, and promotingpatient self-management. The benefits of this includeaccess to effective evidence-based talking therapies in amanner that suits the individual. Time and effort is savedon travelling for all involved, reducing costs for both theindividual and the service provider. The stigmasometimes associated with psychological serviceprovision has been reduced by involving the therapist asan integral part of cardiac services, thus normalising thisaspect of care and the onward referral process.Through using a stepped-care workforce, the skills andgrade of the therapist are matched to the severity of theproblem, instead of using staff from higher grades toprovide the initial care. Through the stepped-careapproach, the progression of patients from step 1interventions to higher step interventions is based on anassessment of severity of problems and responsiveness tothe previous treatment received. Patients with mild/moderate depression and/or anxiety benefit from brieferpsychological interventions, diminishing the burden andneed for more intensive interventions, thus reducingpressure on the patient, service providers andcommissioners, making care provision more cost-effective.ConclusionClinical supervision has helped the cardiac specialist teamsto reflect on and challenge their approach to providinghealth information to individuals. The cardiac team nowencourages patients to identify their concerns and askquestions so that the information given on their conditionmeets the needs of each individual patient, thereforeengaging and empowering them to take control and managetheir own health. This project offers advantages in terms ofaffordability, flexibility and access for individuals, providingthe ‘right touch at the right time in the right place’.It is possible that this model can be replicated by otherteams of health professionals working with patients withBritish Journal of Cardiac NursingOctober 2014Vol 9 No 10Downloaded from magonlinelibrary.com by 086.188.150.011 on October 10, 2019. 2014 MA He
involved in the cardiac rehabilitation programme, particularly to attend patient appointments and the group education sessions. Carers often highlighted that they experienced high levels of anxiety relating to the patients’ cardiac event and might have been traumatised by seeing their relative h
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Newmark, Adam J. 2002. "AN INTEGRATED APPROACH TO POLICY TRANSFER AND DIFFUSION." Review of Policy Research 19, no. 2: 153. (formerly Policy Studies Review). (ISSN: 1541-132X) Wiley – Blackwell. DIGITAL OBJECT IDENTIFIER (DOI): 10.1111/j.1541-1338.2002.tb00269.x An Integrated Approach to Policy Transfer
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