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Community Rehabilitation Services

Most coronary heart disease patients in Lanarkshire now have access to a specially trained nurse or health visitor who will make sure they get the right level of care when they leave hospital.

The community heart disease nurse specialists will contact a patient within days of them leaving hospital and arrange a home visit, where they will provide support, help and encouragement to recover.

These nurses have been given special training to help patients work their way back to health using a rehabilitation tool called the ‘Heart Manual’. They will support them through the programme week by week, monitoring their progress, regularly checking their blood pressure and answering any questions they might have.

The Heart Manual is a six-week therapeutic tool that teaches patients how to have a healthier heart by developing skills to manage anxiety, depression and insomnia, as well as improving diet and fitness. Designed by a team at the Astley Ainsley Hospital in Edinburgh, the Heart Manual is used throughout the UK and has been clinically proven to lower the number of patients who are re-admitted to hospital.

The community nurse specialists will also support patients attending the hospital cardiac rehabilitation classes (see menu option on the left for more information) and carry out regular monitoring of a patient’s blood pressure and medication.

When a patient has completed their rehabilitation, the community nurse specialists will make sure they are registered with their GP’s heart disease clinic for lifelong management of their condition. Patients can also be referred to cardiac exercise classes at a local council leisure centre with specially trained gym instructors. For more information on these leisure services, please see the menu option on the left.

The aim is to train a practice nurse, community nurse or health visitor from every GP practice and health centre in Lanarkshire so no patient can slip through the net when they are discharged from hospital and not get the help they need to keep their heart healthy.