Assessment of Outcomes of Rehabilitation Program for Socially At-Risk Patients

OBJECTIVES: Safety-net hospitals are crucial in providing health care regardless of patients' financial means; however, individuals with social risk factors often face challenges in accessing postacute rehabilitation services, leading to functional decline and extended hospital stays. The Bridge to Home program was developed to address these disparities by providing intensive rehabilitation within an acute care setting for patients who lacked access to traditional postacute services. METHODS: This retrospective observational cohort study examined patients enrolled in the Bridge to Home program at a Level I trauma center from April 2019 to December 2022. Participants included adults with significant diagnoses requiring intensive therapy. Data on demographics, Activity Measure for Post-Acute Care scores, and equipment issued were collected from hospital records and analyzed to assess discharge dispositions, length of stay, and functional outcomes. RESULTS: Of 175 patients, 72% were male, and 78% were underfunded or self-pay; 76% were successfully discharged home. Participants showed significant improvement in functional mobility, with 64% of participants scoring >42.9 points, indicating an increase likelihood for discharge home. More than $100,000 in equipment was provided to facilitate safe discharges. CONCLUSIONS: The Bridge to Home program successfully delivered intensive rehabilitation services to underserved populations, resulting in improved functional outcomes and high discharge home rates. Key factors contributing to success included consistent therapy intensity, targeted resources, and multidisciplinary collaboration. This study highlights the feasibility of implementing a multidisciplinary rehabilitation program within acute care settings, improving access and outcomes for socioeconomically disadvantaged patients. Similar programs could be established in other trauma centers to enhance rehabilitation access for patients with significant injuries.