Stepped Care vs Center-based Cardiopulmonary Rehabilitation for Older Frail Adults Living in Rural MA

Inclusion Criteria: * Older adults (greater than 60 years of age) * Live in a Level 1 or 2 state designated rural area in Berkshire County * Has a condition qualifying for reimbursement (by government or private insurance) for cardiac or pulmonary rehabilitation * Score of 4, 5 or 6 on the Clinical Frailty Scale(24) (corresponding to vulnerable, mildly frail, and moderately frail) Exclusion Criteria: Attended pulmonary or cardiac rehabilitation within the previous two years * Resting pulse oximetry \< 85% on room air or while breathing the prescribed level of supplemental oxygen * Unstable asthma with hospital admission or ED visit within previous three months * Severe exercise-induced hypoxemia, not correctable with oxygen supplementation * Acute systemic illness or fever * Complex ventricular arrhythmias * Resting systolic blood pressure greater than 200mmhg * Resting diastolic blood pressure greater than 100mmhg * Orthostatic blood pressure (BP) drop of \>20 mm Hg with symptoms * History of arrhythmia with syncope * Severe symptomatic valvular disease * Unstable angina * Uncontrolled atrial or ventricular arrhythmias * Uncontrolled sinus tachycardia (\>120 BPM) * Uncompensated congestive heart failure * Third degree heart block without a pacemaker * Active pericarditis or myocarditis * Acute cor pulmonale, severe pulmonary hypertension * Resting ST displacement \> 2mm * Uncontrolled diabetes (resting blood glucose \>400 mg/dl) * Conditions other than pulmonary or cardi…