From March 16, 2020 to May 27, 2020, 38 potential participants were identified from electronic health records. Of the 38 potential participants, 15 did not respond and 1 was not contacted due to privacy restrictions. Twenty-two participants were contacted, but 5 were ineligible due to a language barrier. Of the 17 eligible participants, 13 consented but 1 withdrew before the interview; ultimately, 12 participated. Participants ranged in age from 48 to 83 (mean 64.8 years). There were 8 females (66.7%) and 4 males. There were 8 self-identified white individuals (66.7%), 2 were Asian (16.7%), 1 was Black (8.3%), and 1 was multi-racial (8.3%). Staff were all 18-64-years of age and include both men and women of different races and ethnicities (more specific descriptions not reported due to small numbers and privacy protections).
NARRATIVE DESCRIPTION OF CR EXPERIENCE
Patients highlighted the fear, isolation, and disruption of life activities that resulted from the COVID-19 pandemic.
My big change was to avoid the Coronavirus at all costs and I have been holed up in this apartment since the middle of March. [Patient-9018]
I have been completely isolated and I’m terrified of this pandemic. [Patient-9001]
I don't want to go back because I'm still afraid to be in the room with other people. [Patient-9019]
I'm afraid to go outside, and the couple times that I have gone outside, there's so many people out there … a lot aren't wearing any masks and it freaks me out. [Patient-9038]
The effects of the pandemic on health-related behaviors were variable. Some people found behaviors like physical activity easier to maintain, while others found them more difficult.
And ironically, I found more time and more ways to exercise, and I've been eating healthier and less. [Patient-9034]
Previously I got a great deal of exercise, making more frequent trips to the grocery stores and doing more shopping and doing more walking and riding the bus more. So, now that I'm holed up in the place, my exercise has been spotty. [Patient-9018]
Yeah, because I'm home, bored, so I cook. I cook a lot of different meals, different recipes. [Patient-9019]
Participants and staff highlighted the importance of CR to be individually tailored. Many patients praised the adaptability of HBCR.
[About center CR] They would change the music based on the age group. [Patient-9038]
The staff there really adapted and improvised. [Patient-9034]
Home-based cardiac rehab helps individuals focus on how to create that time in their life outside of the center. [Staff-006]
I got a better grasp of how to create a personalized exercise program. I would learn that someone likes dancing, and start looking into Zumba videos, and then it was a success. [Staff-002]
I find out what kinda equipment they have at home. Do they have a blood pressure cuff at home? Do they have a scale at home? Do they have a wearable activity tracker? And build a program based on what they have. [Staff-003]
Some patients preferred in-person sessions, while others preferred the convenience of HBCR, and still others preferred a hybrid mix of in-person and home-based sessions.
The main thing that's wonderful is that I don't have to come up to the hospital. [Patient-9005]
Everything that I get in the Rehab Center I'm getting at, at home. [Patient-9025]
I much prefer in-person, of course. [Patient-9001]
Now, I'm kinda doing both… and I kinda like it that way. [Patient-9029]
An important facilitator for in-person and HBCR was a strong relationship between participants and staff, who serve as source of accountability. They helped patients “feel safe” and troubleshoot technology.
[About center CR] I was going three times a week and loved it. Everyone there I absolutely adore, and I love the idea of having someone making me feel safe when I tried to do the treadmill. [Patient-9001]
I was very worried I was gonna drop dead and have a heart attack. But they assured me, and with Zoom, even when I do my physical exercise, [CR Staff] are right there with me should something, you know, happen. [Patient-9001]
[About Better Hearts] Okay, I'll do it because you asked me to. [Patient-9029]
I always feel like he's my personal cheerleader and it's kind of endearing and fun. [Patient-9029]
[About Better Hearts] It helps me to stay accountable, and I'd like to think that it also has helped the cardiac rehab folks, so they have an idea of what my stats are. [Patient-9034]
It has allowed them to certainly minimize their risk and their exposure, gives them peace of mind, allows them to have their family members participate, which has been really interesting and helpful. [Staff-007]
Group telephone and video wellness sessions were praised by patients.
It was very helpful. I would say that it was, at the beginning of shelter in place, this regular routine. The check in was very helpful from not just the physical perspective, but the mental perspective. [Patient-9024]
We would share each other's experiences and have great conversations. [Patient-9003]
Lots of different people, different ages, different walks of life all come together on these- these Tuesday and Friday Zoom chats and compare and contrast. We're all going through very stressful times above and beyond our heart ailments. It’s interesting to hear other people's perspective. 
Patients and staff had a range of attitudes toward technology tools.
Another app. [Patient-9038]
I wanna do everything with a pen and paper. [Patient-9038]
Absolutely, not a problem [about using an app]. [Patient-9034]
I would like to always do it over Zoom, so if we exercise, I can see what they're doing and give them form correction. [Staff – 003]
I'm not very tech savvy myself. [Staff -001]
Digital tools helped patients remain connected with providers and allowed providers to obtain information and monitor progress. However, patients and staff discussed technology adoption challenges including the mismatch between expected and observed performance, ease of use, compatibility with other systems, and the need for training.
[About Better Hearts] I think it's more handy for [CR staff] to see what we were doing. [Patient-9038]
[About Better Hearts] Apps like these and Fitbit keep me more accountable. [Patient-9034]
[About Tiatros] The whole thing was kinda rolled out, and not a lot of instructions were passed on. And then you're suddenly getting these emails and prompts that said, "Week one has started and you're paired with so-and-so." Well, paired to do what exactly? [Patient-9034]
If Fitbit and the Better Hearts could combine together it would be perfect. [Patient-9024]
[About Map My Walk] He gave me also an app that I use on my phone that now whenever I go out for a walk I hit the app and just measure the distance. This app is good 'cause it records everything. [Patient-9003]
NARRATIVE DESCRIPTION OF HBCR IMPLEMENTATION
Staff interviews revealed that facilitators to implementing HBCR included a team culture that was conducive to change and supported by leadership.
Because we're in a new cardiac rehab program our directors and our staff were really open to new ideas. [Staff-002]
One of the things that I noticed is that the Cardiac Rehab Team works really well together. Every single person on the team contributes. [Staff-005]
Due to COVID-19, when we shut down, we had to figure out a way to see our patients, and we implemented a home-based cardiac rehab program. [Staff-004]
Really critical was support from administration. [Department leadership] was extremely supportive of the whole project, and also very supportive of the move to home-based cardiac rehab. That was despite the fact that at the beginning, we were not getting reimbursed for home-based cardiac rehab. Having that strong level of administrative support was really important. [Staff-005]
The transition to HBCR, incorporating new delivery models and technology, also required supporting staff with new workflows.
I'm an old nurse and I have just recently had to learn how to document in the electronic health record. For me, the software that the hospital uses is challenging. [Staff-001]
I think it's been a big adjustment for people like me who are not used to working at home. The obstacles that I find are that I sit way too much at the computer. [Staff-001]
My home life has always been completely separate. [Staff-001]
Supplying all of us with laptops and IT supports that took some time since none of us had really worked from home before. [Staff-002]
I kind of feel like I'm learning with the patients. [Staff-002]
In HBCR models, providers helped patients use technology tools and form new habits.
Usually I would have to get on the phone with them and walk them through how to troubleshoot. [Staff-007]
[About Zoom] Make sure that they knew how to click on the access code and what the password was. Most people have been able to pick it up but I know that there's some people who need repetitive information. [Staff-006]
I think having us introduce the app to them here in the center has improved the enrollment. [Staff-002]
[About Better Hearts] What I've had to do is remind people to use the app. [Staff-001]
Patients maybe forget because it's not part of their regular schedule. They're not used to having these type of video visits. [Staff-007]
HBCR may be similar to CBCR, but can also pose new challenges (e.g., privacy, patient access to technology).
Some people just aren't comfortable with video… you have your whole house behind you. You may not want to, it's a personal space. [Staff-004]
It's not as good as when you're able to be hands on and you could take an exercising blood pressure while they're in the middle, and you get to see their EKG the whole time. But other than really getting that diagnostic material, it's pretty close to being the same. [Staff-003]
HBCR may be associated with different costs and reimbursement for centers but may reduce some patient out-of-pocket costs.
It was very cost effective for him because he was catching cabs. [Staff-004]
We got a lot of support with getting laptops. [Staff- 002]
Even though we weren't going to be reimbursed we realized the importance of patient care. [Staff – 002]
We've created a billing process, so that's been a big hurdle and we'll see if that's successful. [Staff-006]