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Updated: Jun 4, 2025

A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
A Remote Management-Centric Postdischarge Pathway for Patients Admitted to GIM with Heart Failure
William K Silverstein1, Sarah Lawrason2, Iris Carabuena3
1Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada.
Background:
Few GIM-specific heart failure transition of care (TOC) programs exist. We thus piloted a TOC program for heart failure patients discharged from GIM that incorporates a remote patient management program, Medly.
Methods:
This single-centre, prospective proof-of-concept study described sociodemographic and medical characteristics of included patients, and computed summary statistics to describe clinical and workload outcomes.
Results:
Ten patients (median age: 85) enrolled. There were no heart failure-related deaths, re-hospitalizations, or ED visits within 90 days of hospital discharge. One urgent GIM clinic visit was needed.
Conclusion:
This post-GIM TOC pathway appears to effectively support heart failure patients. Further studies should assess this innovation's scalability.
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