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Updated: Jun 6, 2025
A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
A Novel Approach of Enhanced, Multidisciplinary Rehabilitation Services in the Hospital to Facilitate Home Discharge:
Nicole Langton-Frost1, Annette Lavezza1, Shannon Wilkins2
1Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Department of Physical Medicine and Rehabilitation, Baltimore, MD; Johns Hopkins School of Medicine, Department of Physical Medicine and Rehabilitation, Baltimore, MD.
Objective:
To evaluate the effectiveness of an early, targeted, individualized, intensive rehabilitation program called Rehab2Home, designed to transition surgical patients directly from acute care to home.
Design:
The Rehab2Home program was implemented using a quality improvement (QI) approach between March 2023 and June 2023. The outcomes of the program were compared with a historical cohort of similar patients.
Setting:
Academic medical center.
Participants:
Postsurgical patients (n=74) included were aged 18 years or older, recommended for subacute rehabilitation by physical therapy or occupational therapy, had some level of support at home, mild to no cognitive impairments, and moderate mobility impairments.
Interventions:
Patients received an enhanced rehabilitation therapy program from physical therapy, occupational therapy, speech-language pathology, and consultations with a physiatrist emphasizing readiness for discharge home. The team also conducted weekday interdisciplinary huddles.
Main Outcome Measure(S):
The primary outcome for the evaluation of the program was discharge location from the hospital. Secondary outcomes included the length of hospital stay and emergency department visits and potentially avoidable utilization (PAU) within 30 days of hospital discharge.
Results:
Seventy-four patients were included in the Rehab2Home program, with 66% discharging home compared to 47% in the historical controls. The program resulted in a 1.4 (95% CI, 1.1-1.6) times greater likelihood of discharging home and decreased the proportion of patients with potentially avoidable health care utilization by 63% (Risk Ratio: 0.37, 95% CI, 0.1-0.7), without a significant increase in length of stay (-0.6 days, 95% CI, -2.2 to 1.9).
Conclusions:
The Rehab2Home program for postsurgical patients successfully facilitated home discharges and reduced postdischarge utilization. This model of rehabilitation shows promise for improving transitions of care from the hospital in this population.
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