A Novel Approach of Enhanced, Multi-Disciplinary Rehabilitation Services in the Hospital to Facilitate Home Discharge - The Rehab2Home program.

Abstract

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. Outcomes of the program were compared with a historical cohort of similar patients.

Setting: Academic medical center.

Participants: Post-surgical patients (n=74) included were aged 18 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 inter-disciplinary huddles.

Main outcome measure(s): The primary outcome for the evaluation of the program was discharge location from the hospital. Secondary outcomes included length of hospital stay, as well as emergency room 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 historic 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 healthcare 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 - 1.9).

Conclusions: The Rehab2Home program for post-surgical patients successfully facilitated home discharges and reduced post-discharge utilization. This model of rehabilitation shows promise for improving transitions of care from the hospital in this population.