Move+ at home: Reorganizing Home Hospitalization for an Integrated Rehabilitation Response

Background: The Home Hospitalization (HH) Service of ULS Coimbra, operating since October 2021, identified a critical gap in patient care: delayed access to home-based rehabilitation. Many patients—especially older adults recovering from orthopedic surgery, falls, or strokes—were waiting more than 30 days to begin rehabilitation. This delay often led to prolonged hospital stays or recovery at home without professional support, resulting in functional decline and higher healthcare costs.

 

To address this, the HH nursing team initiated a reorganization that placed rehabilitation at the center of integrated, person-centered care, ensuring timely, continuous, and equitable access to recovery services.

 

Approach: Launched in January 2025, the “Move+ at Home” project reorganized existing HH resources to create a rapid-response pathway for rehabilitation.

Three HH beds were designated exclusively for rehabilitation, managed by five specialist rehabilitation nurses. Key steps included:

• Promoting early referrals from Orthopedics and Neurology;
• Setting clear inclusion criteria (clinical, geographic, and social);
• Guaranteeing admission within 72 hours of referral (≤24h in some cases);
• Designing individualized rehabilitation plans with active involvement of patients and caregivers;
• Providing an average of 15 days of nursing-led rehabilitation supported by a multidisciplinary team (physician, pharmacist, nutritionist, and social worker);
• Ensuring structured discharge communication and continuity with primary care.

Future developments include the introduction of tele-rehabilitation tools and collaboration with municipalities to address social determinants and home accessibility barriers.

 

Results: Between January and October 2025, the project demonstrated measurable impact:

• 342 patients treated by HH; 47 included in the rehabilitation pathway.
• 100% admitted within 72 hours; 10 within 24 hours.
• Mean age >65 years, mostly female and referred by Orthopedics.
• Functional Independence Measure (FIM) improved from 70.8 at admission to 87.1 at discharge.
• All caregivers were trained in self-care and therapeutic management.
• Average hospital stay reduced by 7 days per patient, saving approximately €1,800 per patient and €84,000 in ten months (annual projection >€100,000).
• High satisfaction rates reported by patients, caregivers, and professionals.
• Positive environmental impact through reduced travel and efficient resource use.

 

Implications: Move+ at Home shows how a strategic reorganization of existing services can bridge a critical gap in access to rehabilitation. The model promotes functional recovery, strengthens caregiver capacity, reduces institutional costs, and contributes to environmental sustainability.

This is a low-cost, high-impact, and replicable model that any HH servisse can adopt. By transforming an access problem into an integrated, person-centered solution, the project advances the IFIC vision—demonstrating that integrated care can be achieved through innovation, collaboration, and smart use of existing resources.