Reframing post-heart attack recovery into a patient-centered care pathway

Challenge

The Canadian Cardiovascular Society (CCS) is making the shift from guideline creation to helping to actually change practice. As a landmark first step, Pivot was brought on-board to help develop a direct-to-patient tool that supports timely self-management and empowers active participation in recovery. The primary goal was to create an accessible, bilingual paper-based "patient passport" that structures immediate discharge steps, promotes long-term care plan adherence, and highlights validated online resources.

Process

We engaged the core project team — cardiologists, and patient/caregiver representatives to co-design a paper-based "patient passport" across three recovery phases post-heart attack. We held a number of sessions with the working group to frame the information hierarchy of the patient-facing tool, using the provider-facing Post-Acute Coronary Syndrome (ACS) Secondary Prevention Pathway as a starting point. The primary goal was to structure complex clinical information into digestible, plain-language sections. 

Solution

We organized critical health actions into three intuitive, time-based phases—Upon Discharge, In the First Month, and After One Month—to avoid information overload during early recovery. 

A print-ready, accessible booklet was developed, featuring:

• Emergency warning signs and clear, phased recovery steps
• Detailed medication guides covering drug types, functions, and adherence planning
• Interactive logs for tracking care teams, appointment dates, blood pressure, and cholesterol/blood sugar levels
• Goal-setting worksheets tailored for short- and long-term lifestyle changes
• Embedded QR codes providing immediate access to expert-approved digital resources on the CCS website