Developing a Collaborative Model for Cardiac Rehabilitation　― Linking Hospitals and Local Fitness Centers for Older Adults With Cardiovascular Disease ―

Abstract

Background: Cardiac rehabilitation (CR) is a comprehensive program designed to help cardiac patients reintegrate into social life. The maintenance phase (phase III) is typically conducted in hospitals or at local exercise facilities, depending on individual lifestyles. Effective collaboration between hospitals and local exercise facilities is essential for maintaining CR in older adults with cardiovascular disease (CVD), but several barriers hinder this linkage.

Methods and Results: Since 2022, the Aichi Health Plaza has maintained CR by developing a unique collaboration handbook (the Cardiac Rehabilitation Exercise Facility Cooperation Medical Institutions [CREpas] handbook). A collaboration system was established with the Department of Cardiology at the National Center for Geriatrics and Gerontology, facilitating seamless transitions through referrals after outpatient center-based CR. Partnerships included methods for information sharing, such as a collaboration diary, training records, occasional telephone calls and emails, and biannual information exchange meetings. A total of 18 collaboration patients was enrolled, and no severe adverse events occurred during exercise. However, 11 (61%) of the 18 patients discontinued the program for various reasons.

Conclusions: Transferring CR from hospitals to fitness centers is crucial for older adults with CVD. While safety was ensured at fitness centers, program interruptions highlight the need for addressing barriers to continuity. Seamless healthcare transitions for older CVD patients remain a key challenge in the context of the heart failure pandemic and require further discussion.

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide, with a significant impact on healthcare costs, population well-being, and workforce productivity.¹ In Japan, the number of patients with heart failure, estimated at approximately 1.2 million, continues to rise and is projected to reach around 1.3 million by 2030.² Among these patients, older adults account for 80% of the total.³ This population is at an increased risk of requiring nursing care or hospital readmission due to disuse syndrome and inadequate lifestyle management caused by prolonged bed rest.⁴

In older patients, effective long-term and comprehensive management after CVD treatment is essential.⁵ Cardiac rehabilitation (CR) is a comprehensive program designed to help cardiac patients reintegrate into social life while preventing disease recurrence and hospital readmissions.⁶ CR encompasses exercise therapy, patient and family education, counseling, nutritional and dietary guidance, medication, and lifestyle management.⁵ Among these, exercise therapy plays a crucial role, as it improves motor functions such as exercise tolerance and muscle strength, which cannot be adequately addressed through pharmacotherapy alone. These improvements contribute to the maintenance and enhancement of activities of daily living (ADL) and overall quality of life.

CR is typically classified into 3 stages: the ‘acute phase’, spanning from the onset of illness to hospital discharge; the ‘recovery phase’, following discharge; and the ‘maintenance phase’, which continues throughout the patient’s life after reintegration into society.⁵ The maintenance phase is generally conducted at a hospital or a local exercise facility, depending on the individual’s lifestyle. Exercise therapy in this phase effectively maintains and improves exercise capacity, endurance, and muscle strength.⁵

Despite its benefits, participation in outpatient CR after hospital discharge remains low. A survey by the Japanese Heart Failure Society revealed that only 7.3% of patients deemed eligible for outpatient CR actually participated.⁷ Patients who complete phase II CR often struggle to maintain regular exercise after the program ends, even though consistent exercise prevents future cardiac events. To address this, phase III CR is recommended to sustain the benefits achieved during phase II.⁸ Barriers to participation from the patient’s perspective include advanced age, financial and time constraints, and low motivation. For medical institutions, challenges include limited knowledge about CR, insufficient staffing, and inadequate facilities for outpatient care.

Local exercise facilities, which could serve as alternative venues for maintenance-phase CR, remain underutilized, and reports on their activities are sparse. Additionally, collaboration between hospitals and standalone exercise facilities not affiliated with medical institutions is limited, creating further obstacles. To address these challenges, the National Center for Geriatrics and Gerontology (NCGG) launched a collaborative model between hospitals and local exercise facilities for phase III CR in 2022. This initiative establishes a framework for providing maintenance-phase CR and highlights its successes and areas needing improvement in older adult patients with CVD.

Methods

Population

To ensure safe and reliable CR at Aichi Health Plaza (AHP), the following criteria were used for patient inclusion: (1) patients were treated for CVD at the abbreviation NCGG and, after discharge, successfully participated in outpatient CR for at least 4 months (Figure 1); (2) patients were classified as having heart failure stage C with stable symptoms, diet, and medication, and were authorized to exercise at AHP by their attending physician and physiotherapist; and (3) patients, including their family members, consented to transfer from the hospital to the fitness center after a doctor or physiotherapist explained using a fitness center as part of phase III CR.

Figure 1.

Seamless healthcare system from the hospital to the fitness center. Phases I and II, II and III overlap. CR, cardiac rehabilitation.

This study was conducted in accordance with the Declaration of Helsinki and received approval from the AHP ethics committee (Approval no. 2024-06). Due to the study’s retrospective design, informed consent was deemed unnecessary under national regulations issued by the Japanese Ministry of Health, Labour, and Welfare. However, the opt-out method was used, with relevant information posted on the AHP website.

Location

The exercise facility, AHP, is a health promotion center managed under the jurisdiction of Aichi Prefecture. It features a 453.19 m² training room and an indoor track with a circumference of 180 m. The facility serves approximately 5,000 users annually and is equipped with 26 pieces of aerobic exercise equipment, including bicycle ergometers, treadmills, and 29 strength training machines spanning 19 different types of machines. Exercise instructors and public health nurses manage the training rooms. All patients participating in CR at AHP were referred by the NCGG. While the NCGG is adjacent to AHP, it operates as a separate management entity.

Background to the Collaboration

The collaboration between AHP and the Cardiology Department of the NCGG began in 2022. The Cardiology Department recognized a growing need for patients to continue CR beyond the 5-month insurance coverage period. The staff proposed developing a system to ensure seamless maintenance-phase CR. This initiative aimed to establish a reliable follow-up system for patients transitioning from outpatient CR to ongoing rehabilitation at AHP.

Collaboration Between the Hospital and Fitness Center

Regarding sharing patient information between the 2 parties, it was decided that the patient’s treatment, CR status, physical condition, and precautions should be shared through the collaborative notebook and biannual joint conferences (Figure 2). The coordination handbook (Cardiac Rehabilitation Exercise Facility Cooperation Medical Institutions [CREpas] handbook; Figure 3) links medical institutions, patients, and exercise facilities. It consists of: (1) an introduction to the handbook; (2) notes on exercise; (3) an introduction to the coordination facilities; (4) treatment progress and rehabilitation details; and (5) exercise records. Items 1–3 are information pages for patients who use exercise facilities. In item 4, the medical institution describes the treatment course and exercise prescription and shares them with the exercise facility. Item 5 is a description from the exercise facility detailing the patient’s exercise content and physical condition at the time of exercise that is shared with the medical facility. Based on the coordination notebook, the exercise category, intensity, and duration of exercise performed during CR should be followed while checking the subjective exercise intensity (Borg index). The patient’s physical condition is checked before and after each CR, and blood pressure and heart rate are measured.

Figure 2.

Corroboration between hospital and fitness center.

Figure 3.

Cardiac Rehabilitation Exercise Facility Cooperation Medical Institutions (CREpas) handbook.

Results

Experienced Patients From Hospital to Fitness Center

A total of 18 patients had CR at the AHP: 4 each in 2022 and 2023, and 10 in 2024 (Table). Half of them were in the form of continuing CR with a combination of twice-monthly outpatient CR performed within the insurance scheme and twice-monthly use of this facility.

Table.

Baseline Characteristics

Year	Age (years)	Sex	Cardiac condition	Progress
2022	87	F	HF	After outpatient CR, the patient continues to exercise once a week. Assessed at the start, and at 1 and 2 years, results were as follows: body mass index 28.7, 26.9, and 26.6 kg/m2; body fat percentage 34%, 32.9%, and 29.5%; estimated maximal oxygen uptake 21, 23.2, and 22.4 mL/kg/min; all kept improving from the baseline.
	76	F	Persistent AF	After outpatient CR, the patient started exercising twice a week and continued for 9 months.
	81	F	Aortic stenosis	The patient aimed to exercise once a week, in combination with outpatient CR; she became irregular and suspended participation.
	86	F	HF	The patient aimed to exercise once a week, in combination with outpatient CR; she is now only exercising a few times a month but is walking at home, and her insomnia has resolved.
2023	86	F	Atrial septal defect	Outpatient CR twice a month to continue exercise and is now using it regularly.
	83	F	Paroxysmal AF	Outpatient CR twice a month, aimed to use the facility twice a month to continue exercise, interrupted after 4 months, resumed with spouse, used several times, and then was interrupted.
	81	F	AMI	Outpatient CR twice a month, started exercise at the facility twice a month in addition to exercise at home to continue training, continued for 5 months, but was interrupted after 5 months.
	92	F	Angina pectoris	Outpatient CR twice a month, started using the service with family transportation to continue exercise, aiming for twice a month, but only used the service the first time.
2024	80	M	HF, persistent AF	Outpatient CR was twice a month and the patient started using the service twice a month, in addition to golf as a hobby, to continue exercise, but discontinued after 3 months of continuous use.
	87	M	Angina	Outpatient CR was twice a month, in addition to exercising at home, started using the service twice a month with a spouse who was using it earlier but discontinued after 2 months.
	81	M	AMI	Outpatient CR was twice a month and started using the service twice a month to continue exercise, but discontinued after using it for once a month for 3 months.
	84	F	Persistent AF	Outpatient CR was twice a month and the patient started using the service twice a month as a guide, in addition to exercise at home, to continue exercise, and continues regularly.
	74	M	Angina, persistent AF	The patient started using the service because he could not attend CR during the day due to work, and continues 1–2 times a week.
	77	M	Angina pectoris	Outpatient CR twice a month, started with the aim of using the service twice a month in addition to exercise at home to continue exercise, but has not used the facility since the first use.
	72	M	Mitral regurgitation	The patient started using the service as his condition stabilized with outpatient CR, in addition to exercising twice a month at home, but was interrupted because of back pain in the middle; he used it several times but discontinued.
	50	M	AMI	The patient has been using the facility for a long time, but because of work he cannot attend CR during the day; after 2 weeks of CR, he continues to use the facility twice a week.
	85	F	Sick sinus syndrome	Outpatient CR twice a month, started using the service twice a month with family transport to continue exercise, no use since the first use.
	70	M	Angina pectoris	Outpatient CR twice a month, started using the facility 1–2 times per week as a guide to continue exercise.

AF, atrial fibrillation; AMI, acute myocardial infarction; CR, cardiac rehabilitation; F, female; HF, heart failure; M, male.

At present, the proportion of interrupted users (11 [61%] of 18) is higher than that of continuing users (Figure 4). The intensity and amount of exercise were started based on the exercise prescription at the beginning of the CR, and no accidents occurred during training at the facility.

Figure 4.

Continuity rate for maintenance of cardiac rehabilitation at Aichi Health Plaza fitness center.

Representative Cases

Two case studies are presented. The first case is that of an 87-year-old woman. After admission to the NCGG for heart failure, she underwent outpatient CR for 4 months and was transferred to use the AHP. She performs 2 sets of 15 min on the bicycle ergometer once a week, with 1 set of 15 strength training in between, 6 exercises (3 lower-limb exercises, 1 upper-limb exercise, 1 abdominal exercise, and 1 back exercise), and stretching before and after the exercises. According to the results of the annual health check, body mass index (kg/m²), body fat percentage (%), and estimated maximal oxygen uptake (mL/kg/min), an indicator of total body endurance, continued to improve 2 years after the baseline of the program. Assessed at the start, and at 1 and 2 years, results were as follows: body mass index was 28.7, 26.9, and 26.6 kg/m²; body fat percentage was 34%, 32.9%, and 29.5%; estimated maximal oxygen uptake was 21, 23.2, and 22.4 mL/kg/min; all kept improving from the baseline.

The following case study is of an 81-year-old woman. The patient was referred to AHP because she had aortic stenosis and underwent replacement surgery, followed by CR for 4 months outpatient CR at NCGG, and then continue exercise therapy at AHP twice a month. Exercise therapy at AHP twice a month. Her family transported her to AHP where she performed 15 min of bicycle ergometer, 1 set of 10 strength training, 5 exercises (4 lower-limb exercises, and 1 abdominal exercise), and stretching before and after the exercises. Assistance was required to get her on and off the machines. Initially, she was able to perform the exercises twice a month, but later she used the machine once a month and then once every 2 months, and after 9 months she stopped.

Discussion

The initiation of CR collaboration between the hospital and local exercise facilities has facilitated patient acceptance and information sharing. The continuation of CR might be effective in maintaining and improving exercise tolerance. However, there were some interrupted cases among referred patients, and there were scattered cases of interrupted exercise continuation under the supervision of the exercise facility. This is critical to address in terms of achieving long-term rehabilitation goals.

Collaboration Between Hospitals and Fitness Centers

CR provides exercise training linked to improved outcomes, encompassing enhanced exercise tolerance and a more favorable prognosis. Ensuring the continuity of CR, transitioning seamlessly from the inpatient to the outpatient maintenance phases, is crucial in managing the underlying disease effectively.⁶

Reasons for the smooth acceptance by patients and information sharing at the hospital and exercise facility, which were separate operational entities, included the establishment of face-to-face relationships, organization of the patient acceptance target in advance and the operational flow, and the use of the coordination handbook and verbal information sharing. The collaborative notebook allows the sharing of exercise content and precautions during CR so that the instructors can provide exercise guidance with peace of mind. During regular joint conferences, specialists from the cardiology department of the NCGG explain the pathological conditions of the patients, which helps to deepen the understanding of each patient’s condition and clarify any questions regarding the adjustment of exercise intensity during daily exercise instruction, leading to improved instruction.

Safety and Effective Acceptance in Phase III

A possible reason for patients accepting that the program is safe and effective is that the facility has originally had experience in providing exercise guidance to people with illnesses, and in accordance with the American College of Sports Medicine guidelines⁹ and the Physical Activity and Exercise Guidelines in Japan,¹⁰ health information and medications are checked before use. During each exercise session, the patient’s physical condition is checked and the patient is made aware of their condition. Having experienced exercise guidance, in which the patient’s physical condition and subjective exercise intensity are checked before each exercise session, and the intensity and volume are gradually increased, has been helpful in this regard.

In a report on interrupted CR cases, a systematic review of 29 existing studies analyzing factors affecting participation and adherence to CR programs by patients with acute myocardial infarction¹¹ found that individual-related factors that prevented participation in CR were older participants, women, and patients with comorbidities.¹² Also, aspects affecting CR, such as living further away from the facility and needing transport, or not being able to drive, were associated with less participation in the CR program. There were scattered cases of barriers to accessing the facility among patients in this case study, which is a finding consistent with previous studies.^13,14

Adherence of CR in Phase III

Collaboration between hospitals and community health organizations can significantly enhance population health.^15,16 However, further research is needed to determine which types of collaboration are most effective, for whom, and under what circumstances. Ultimately, local collaborations should be understood within their macro-level political and economic context, as part of a more extensive system of factors and interventions that collectively shape population health.

In the present study, 61% of fitness center dropouts were attributed to factors such as anxiety, increasing frailty, difficulties in accessing the fitness center, and a lack of interest in exercising. A previous study reported a 54% adherence rate to follow-up CR programs during phase III.¹⁷ This suggests that maintaining adherence to phase III CR programs can be particularly challenging for older adults with CVD. However, for those who can participate in a CR program at fitness centers during phase III, engage in ‘lifestyle exercise’ (e.g., walking, taking the stairs, parking further away, light gardening, dancing) and participate in structured physical activities, then there is a significant benefit.

At present, there is limited convincing evidence to suggest that collaboration between local organizations and non-healthcare entities consistently improves health outcomes. The impact on health services and resource use remains mixed, with some studies reporting varying results. Despite this, many studies have identified factors associated with better or worse collaboration.¹⁸ As a challenge, we considered that there would be cases who left during the project and that we could explore ways to increase the number of CR cases at the fitness center during phase III.

Study Limitations

This was a single-center and fitness-center study with a small sample size. Moreover, we did not check changes in the trajectory of exercise capacity or frailty due to medical intervention or CR. Last, the findings of our study, based on a non-randomized design, are largely hypothesis-generating and call for similar analyses of more extensive and more recent databases, prospective follow-up studies, and confirmation through randomized clinical trials.

Conclusions

A model initiative for CR collaboration between hospitals and local exercise facilities was initiated at the NCGG and an AHP, which are separate operational entities, and patient acceptance and information sharing have been smooth. There have been no accidents during the implementation of exercise, and it has been carried out safely. In contrast, there were scattered interruptions, where there were obstacles for the patients in accessing the facility, and it was considered necessary to seek the understanding of family members and other collaborators to prevent interruptions.

Acknowledgments

We thank the staff members of the National Center for Geriatrics and Gerontology (Obu, Japan), Shunya Tanioku, Katsunori Hara, Koharu Oya, Junpei Sugioka, Shigeharu Tsuzuki, Moeka Isomura, and Hideki Yanagisawa (Physical Therapists), as well as Yoshiko Suzuki, Chinatsu Makita, Chieko Hokao, and Kaori Inaguma (Research Assistants).

Sources of Funding

This work was supported by the National Center for Geriatrics and Gerontology (Grant no. 22-9).

Disclosures

There are no conflicts of interest to declare.

Author Contributions

T.O., A.H., H.K., I.U., S. Sakakibara, M.W., Y.H., and A.S. contributed to the study conception, design, and material preparation. T.O., H.A., K.H., I.U., T.Y., T.K., M.K., S. Sakakibara, M.W., and A.S. collected the data. T.O., A.H., K.H., I.U., and K.K. performed data analysis. T.O. wrote the first draft of the manuscript. A.H., S. Suzuki, M.M., H.A., and A.S. supervised the work. All authors read and approved the final version of the manuscript.

Data Availability

The deidentified participant data will not be shared.

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