ArticleFrontiers in cardiovascular medicine2026
Identification and analysis of breakpoints in "hospital-community-family" cardiac rehabilitation for chronic heart failure patients based on patient journey map: a qualitative study.
Article in Frontiers in cardiovascular medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Objective: Applying patient journey mapping technology to identify and analyze structural gaps in the "hospital-community-home" cardiac rehabilitation continuum for patients with chronic heart failure, thereby providing empirical evidence for optimizing service linkage. Methods: Using a purposive sampling strategy, 15 patients with chronic heart failure (NYHA functional class II-III) were recruited from the cardiology department of a tertiary hospital between March and June 2025. Data were collected through semi-structured interviews, and inductive content analysis was employed to code and categorize the data. A patient journey map was constructed to visualize the pain points and gaps in the rehabilitation process. Results: The study identified nine critical fracture points along the rehabilitation pathway, categorized into three core dimensions: (1) structural fractures (hospital-to-community transition), manifested by the lack of standardized referral processes, discontinuous rehabilitation information transfer, and disparities in access to professional resources; (2) functional fractures (community-to-home transition), manifested by unsystematic home rehabilitation guidance, lack of monitoring methods, and insufficient construction of family support systems; (3) systemic fractures (throughout the entire process), manifested by the absence of multidisciplinary collaboration, inconsistent evaluation standards, and lack of remote support. The formation of these fracture points stems from multiple factors, including uneven allocation of health system resources, inadequate collaboration mechanisms among medical institutions, and insufficient rehabilitation health literacy of patients. Conclusion: Rehabilitation services for patients with chronic heart failure exhibit significant vulnerabilities in inter-institutional continuity. In response to the identified points of fragmentation, it is recommended to establish a standardized referral system, strengthen family empowerment support systems, and promote the development of intelligent rehabilitation management platforms. These measures aim to bridge service gaps, enhance rehabilitation continuity, improve quality of life for heart failure patients, and reduce readmission rates.
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