Running Head: HEART TO HEART Heart to Heart: A Cardiac Rehabilitation Follow-up Program by Tamara H. Bisbee B.S.N., University of Minnesota, 1979 M.A., St. Michael’s College, 1993 DISSERTATION Submitted in partial fulfillment of the requirements for the degree of Doctor of Psychology in the Department of Clinical Psychology of Antioch University New England, 2012 Keene, New Hampshire Department of Clinical Psychology DISSERTATION COMMITTEE PAGE The undersigned have examined the dissertation entitled: HEART TO HEART: A CARDIAC REHABILITATION FOLLOW‐UP PROGRAM presented on June 29, 2012 by Tamara H. Bisbee Candidate for the degree of Doctor of Psychology and hereby certify that it is accepted*. Dissertation Committee Chairperson: Susan Hawes, PhD Dissertation Committee members: Victor Pantesco, EdD Thomas Stearns, PhD Accepted by the Department of Clinical Psychology Chairperson Kathi A. Borden, PhD on 6/29/12 * Signatures are on file with the Registrar’s Office at Antioch University New England. HEART TO HEART ii Dedication This dissertation is lovingly dedicated to my grandfather, Max Vaughn Hammitt who, hours before his heart failed, dreamt me up to query “if not now, when?” And to my grandchildren Sophia and Carter whose pure love and aliveness has awakened me to the extraordinarily loving nature of my Grandfather’s final quest. HEART TO HEART iii Acknowledgments The care of several individuals has enabled me to finally complete this project during a difficult and complicated time in my life. I am grateful to my dissertation committee members who hung in with me to the end. Thanks to Dr. Susan Hawes for unending support and evenly hovering attention, and to Dr. Tom Stearns for thoughtful consideration of my work and making himself available with precise timing. Thanks to Dr. Vic Pantesco whose wisdom and word wizardry provided remarkable intellectual containment for my doctoral training experiences, and whose humor has sustained me though and beyond. Special thanks to Limpy Jim, honorary dissertation committee member who holds the secrets of a well-lived life; humility, humor and a firm allegiance to irony. I owe a tremendous debt of gratitude to Dr. Melvin Miller whose incorrigible fascination with the life of the mind has been my constant companion in this work. Loving thanks to Elizabeth Seward, M.D. Finally, I want to acknowledge my family. Thanks to my three favorite women: Megan, Clare and Jaime. Your love and life adventures always inspire and sustain me in my own journey. To David, my life partner: thank you from the bottom of my heart for so courageously looking into the dragon’s mouth. It allows me great faith in the power of love and in my life’s work. HEART TO HEART iv Table of Contents Dedication .................................................................................................................................. ii Acknowledgments...................................................................................................................... iii Abstract ...................................................................................................................................... 1 Chapter 1 .................................................................................................................................... 3 Secondary Prevention of Coronary Heart Disease ................................................................ 3 Statement of the Problem ...................................................................................................... 4 Proposed Program ................................................................................................................. 4 Chapter 2: Literature Review .................................................................................................... 7 Coronary Heart Disease ....................................................................................................... 7 Pathophysiology ............................................................................................................... 8 Risk factors ...................................................................................................................... 9 Cardiac Rehabilitation .......................................................................................................... 17 Cardiac psychology .......................................................................................................... 20 Compliance: Sustained behavior change ......................................................................... 19 Tele-health: Telephone counseling ................................................................................. 29 Chapter 3: The Program ............................................................................................................ 31 Methodology ......................................................................................................................... 32 Conceptual Framework ......................................................................................................... 37 Transtheoretical Model .................................................................................................... 37 Motivational Interviewing ............................................................................................... 46 Chapter 4: Program Design and Procedures ............................................................................. 53 The Heart-to-Heart Follow-up Program ............................................................................... 53 HEART TO HEART v Program Evaluation .............................................................................................................. 61 Discussion ............................................................................................................................. 72 References .................................................................................................................................. 76 Appendix A ................................................................................................................................ 92 Abstract This dissertation describes a tele-health follow-up program designed to attend to the problem of noncompliance in the process of health-behavior change after formal Cardiac Rehabilitation treatment at a southern New Hampshire community hospital. Cardiac Rehabilitation treatment encompassing lifestyle behavior change is associated with a significant reduction in morbidity and mortality in individuals with Coronary Heart Disease. However, evidence that adherence to lifestyle behavior change recommendations diminishes significantly within six months of treatment suggests that noncompliance is a significant barrier to the secondary prevention of a disease with prodigious consequences. Accumulating evidence that Cardiac Rehabilitation treatment encompassing extended duration of contact with the treatment team is associated with long-term health-risk behavior change as well as significantly fewer clinical events provides rationale for development of this program. Consistent with the identified outpatient treatment program, the proposed aftercare program aims to achieve significant and sustained changes in risk-factor related lifestyle behavior areas. Based on the conceptualization that behavior change is an ongoing dynamic process that encompasses repeated cycles of relapse, the program provides ongoing telephone sessions over the first year after discharge from the outpatient program. The Transtheoretical Model of Change as it interacts with the principles of Motivational Interviewing provide the foundation for planning and facilitating interventions that are relevant to the patient during each contact. The RE-AIM Model guided the development and formative evaluation of the program. The proposed plan for summative program evaluation is based on guidelines provided by the American Association of Cardiovascular and Pulmonary Rehabilitation, and assesses outcomes in Health, Clinical, Behavioral and Service Domains. Barriers to implementation of the proposed program include financial issues as they interact with HEART TO HEART 2 the necessity for provider training and the current economic environment that impedes the implementation of adjunct programs within the health-care system. Keywords: cardiac rehabilitation, lifestyle behavior change, adherence, Transtheoretical Model of Change HEART TO HEART 3 Chapter 1 Coronary Heart Disease (CHD) is the single largest cause of mortality and disability in the United States (American Heart Association, 2006). Evidence that risk for future CHD events is significantly higher for individuals who already have CHD, (Benhorin, Moss, & Oakes, 1990; Kannel, Sorlie, McNamara, 1979; Ulvenstam et al., 1985) has made the rehabilitation and secondary prevention of CHD a compelling focus within the health care system. While Cardiac Rehabilitation programs aimed at lifestyle risk-factor modification have become standard of care in the secondary prevention of CHD related morbidity and mortality, lack of long-term maintenance of lifestyle changes has become a central focus. This dissertation describes a tele-health follow-up program designed to promote long-term compliance after outpatient cardiac rehabilitation treatment at a community hospital in southern New Hampshire. Secondary Prevention of Coronary Heart Disease Coronary heart disease (CHD) is associated with numerous risk factors that both include and are mediated