Referral to and discharge from cardiac rehabilitation: key informant views on continuity of care.

Objectives: To assess the system-level barriers and facilitators of continuity of care from acute care to cardiac rehabilitation (CR), and from CR discharge to follow-up with primary health care providers.
Method: Semi-structured individual interviews with 24 key informants including CR staff, research scientists, policy makers, cardiologists and other doctors from a regional to international level were conducted regarding the processes of referral to and discharge from cardiac rehabilitation. Key informant interviews were audio taped, transcribed, and imported into QSR N6 software for Grounded analysis.
Results: Themes that emerged related to communication, referral and discharge processes, health care provider practices, inter- and intra-institutional relationships, and alternative models of delivery to improve continuity.
Conclusions: Ramifications for enhancing referral of patients to beneficial CR services and follow-up by primary care providers to ensure maintenance of functional and health-related gains are discussed.