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Table 5 Social ecological model

From: A systematic review of provider-and system-level factors influencing the delivery of cardiac rehabilitation for heart failure

Level of influence Barriers Potential solutions
Individual Healthcare professional • Establishing inter-professional collaboration forums (e.g. working groups, knowledge-sharing meetings)
• Developing collaborative relationships between health professionals looking after HF patients
Microsystem The organisation of CR programmes • Using new delivery systems such as telemedicine
• Providing choice between hospital-based group rehabilitation and home-based individual programmes
• Providing feedback to programmes regarding the management of their HF patients
Mesosystem The organisation of healthcare system • Providing integrated healthcare
• Developing local patient pathways
• Using automatic referral systems
Exosystem Education • Education programmes for healthcare professionals on the importance of exercise training
Medical insurance • Better collaboration with healthcare authorities
• Increasing insurance coverage
Resources • Inclusion of CR for HF in local commissioning contracts
• Changes to healthcare systems that improve access to CR by removing some of the financial constraints (such as accountable care organisations under the new Affordable Care Act in the United States)
Macrosystem The origins of CR and previous practices • Initiatives influencing awareness of the importance of CR (e.g. the Cardiac Rehabilitation Network of Ontario)
Evidence-base • Increasing the evidence-base confirming the benefits and safety of CR in patients with HF (especially HFpEF)
Guidelines • Development of cross-institutional guidelines
• Combining and translating guidelines into clinical algorithms (to reduce practice variation and increase guideline adherence)
• Better implementation of existing guidelines
  1. CR Cardiac rehabilitation, HF heart failure, HFpEF Heart failure with preserved ejection fraction