Building Effective Hybrid Rehabilitation Programs: Clinical, Operational, and Technological Considerations

By: Chad E. Cook, PT, PhD, FAPTA

Background: Over the past several years, I have served on Daniel Harvey’s PhD dissertation committee. His work centers on process variables in rehabilitation, defined as modifiable and measurable factors within a care pathway that, when altered, may lead to different operational or patient outcomes [1]. These variables encompass elements such as the amount and timing of treatment, the sequencing and coordination of care, the content and timing of information provided to patients, and the prevention of unnecessary or low‑value interventions [2]. Within this framework, hybrid rehabilitation represents an approach that integrates several key process variables, particularly treatment dose, timing, coordination, and the platform through which care is delivered. I am confident that hybrid rehabilitation will soon become the standard delivery model and will be expected by insurance providers

Hybrid Rehabilitation: Hybrid rehabilitation is best described as a blended delivery model that combines traditional, in‑person rehabilitation with remote, digital, or home‑based components [3]. It brings together face‑to‑face interventions, germane to physical, occupational, speech, or psychological therapies, with technology‑enabled or home‑supported strategies, such as telehealth visits, app‑based exercise programs, remote monitoring tools, virtual coaching, and digital education modules. Hybrid rehabilitation approaches differ from digital care-only in that intensive face-to-face sessions are provided early (often at a higher cadence) and are followed up over time with technology-enabled approaches. The result is a coordinated approach that extends care beyond the clinic while maintaining structured therapeutic oversight.

Most hybrid rehabilitation models include six key components.

• Early Face-to-Face Care: The process begins with an in‑person evaluation to identify impairments, establish goals, and design a safe, individualized plan. This foundation is reinforced through weekly, biweekly, or individually-tailored clinic visits, where hands‑on, supervised treatments, reassessment, and progression occur.
• Telehealth-Based Check-in: Between clinic sessions, telehealth check‑ins provide continuity. These touchpoints allow for timely exercise adjustments, troubleshooting of barriers, and ongoing relationship‑building, an important factor in reducing obstacles to self‑care, as widely documented in the literature [12].
• Daily Application-Supported Exercises: Daily home exercise programs, supported by a digital application with clear video demonstrations, extend care into the patient’s routine. Support tools and check-ins can counter factors such as reinforcement and restricted resources, which are considered barriers to completion of a home exercise program [13].
• Wearable Technologies: Because outcomes are influenced by more than exercise alone, wearable technology is incorporated to monitor relevant metrics such as step count, range of motion, proportion of sedentary time, or heart rate, depending on the condition being treated.
• Self-Management and Education: Self‑management and education in hybrid rehabilitation focus on giving patients the knowledge and confidence to take an active role in their recovery, both during clinic visits and at home. Digital platforms deliver condition‑specific learning modules, exercise instructions, and symptom‑management strategies in formats that are easy to revisit, such as short videos, interactive guides, and progress dashboards.
• Ongoing Outcomes Assessment: Finally, digital outcome tracking through structured questionnaires ensures that progress is measured consistently and that care remains responsive to the patient’s evolving needs.

The Evidence for Hybrid Rehabilitation: Providers have often embraced new healthcare practices before their effectiveness was thoroughly established. Shared decision making is a clear example of early adoption: by 2017 it had already been fully endorsed by major healthcare organizations, including Agency for Healthcare Research and Quality (AHRQ), and incorporated into the Affordable Care Act, even though no comparative studies involving musculoskeletal disorders had yet evaluated its impact [4]. Since the published systematic review [4], additional work has shown that when shared decision-making is framed or implemented poorly in populations with musculoskeletal disorders, it can produce outcomes that are no better and, in some cases, worse than usual care [5–9].

When evaluating a hybrid rehabilitation approach with early intensive face-to-face care, followed by technology-enabled strategies (for musculoskeletal disorders), I found only one small completed study [10]. There are published protocols for ongoing studies, but results are not yet available. The single study [10] showed that a hybrid rehabilitation model for musculoskeletal performed as well as traditional in‑person rehabilitation, with added advantages in flexibility, accessibility, and patient engagement.

Despite the sparse evidence, the Centers for Medicare and Medicaid Services (CMS) in the United States positions hybrid rehabilitation as a core strategy in the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model [11]. The model explicitly aims to expand access to technology‑supported chronic care, including telehealth, remote monitoring, digital platforms, and other virtual tools, and even ties payment to measurable improvements in patient outcomes rather than service volume.

Best Practice: While the ideal workflow will vary slightly from person to person, several core components consistently form the backbone of high‑quality, coordinated, hybrid rehabilitation. Structured training and ongoing professional development help clinicians deliver high‑quality care across delivery platforms. This includes mastering new competencies, such as digital etiquette, remote assessment techniques, technology troubleshooting, and virtual rapport‑building. The following are recommended areas of advanced study:

• Patient Engagement Strategies: Effective engagement in hybrid musculoskeletal rehabilitation requires approaches that translate seamlessly across in‑person and digital environments. Providing clear, accessible education about the condition and the rationale behind each intervention helps patients understand their role and remain motivated. Collaborative goal‑setting ensures that rehabilitation activities feel meaningful and achievable, regardless of the delivery format. Regular, empathetic feedback, whether offered during appointments or through digital progress‑tracking tools, reinforces progress and supports timely adjustments. Consistent communication through brief check‑ins or secure messaging maintains accountability and sustains engagement throughout the rehabilitation process.
• Aligning Goals and Expectations: Collaborative goal‑setting aligns clinical priorities with the patient’s personal values, such as pain reduction, return to work, or resumption of meaningful activities. This alignment enhances motivation and adherence. Equally important is expectation management: many musculoskeletal conditions improve gradually, and discussing anticipated timelines, normal symptom variability, and the importance of self‑management helps prevent frustration and disengagement. These conversations build therapeutic alliance, create space to correct misconceptions, and allow clinicians to explain the evidence supporting treatment decisions.
• High‑Fidelity Decision Support Tools: Low‑fidelity tools, such as static handouts or generic exercise sheets, offer limited personalization and interactivity, which can reduce understanding and follow‑through. High‑fidelity decision support tools, including option grids and digital decision aids, enhance comprehension by integrating multimodal learning, real‑time feedback, and individualized relevance. These tools can deepen patient understanding of pain management, ergonomics, energy conservation, and other essential self‑management strategies.
• Behavioral Change Coaching: Advanced training in behavioral change coaching is essential in hybrid rehabilitation, where patients must sustain progress between in‑person sessions. Coaching strategies help patients build confidence, develop consistent habits, and adapt routines when symptoms fluctuate. Digital check‑ins, progress dashboards, and supportive messaging reinforce these behaviors and provide continuity across care settings.
• Digital Communication Fluency: Clinicians must communicate clearly, concisely, and empathetically across multiple digital channels, including video visits, secure messaging, and app‑based feedback. High‑quality hybrid care depends on the ability to explain clinical reasoning in plain language, reinforce progress asynchronously, and maintain rapport without physical presence. These skills often require targeted training to ensure that digital interactions feel personal, supportive, and clinically effective.
• Adaptive Teaching and Learning Designs: Adaptive instructional designs allow educational content and therapeutic guidance to adjust to each patient’s abilities, learning preferences, and rate of progress. Flexible digital platforms enable clinicians to tailor the difficulty, pacing, and format of materials, such as videos, interactive modules, or step‑by‑step guides, to match functional level and learning style. Real‑time performance data can inform immediate adjustments, ensuring that patients receive the appropriate level of challenge and support as their condition evolves.

Benefits and Limitations of Hybrid Rehabilitation: Like all healthcare delivery platforms, hybrid rehabilitation offers both benefits and limitations. Because these strengths and limitations often interact in complex ways, a clear comparison helps clinicians, administrators, and policymakers evaluate when hybrid delivery is most appropriate and what safeguards or supports are needed to ensure high‑quality care. The following table summarizes the key benefits and trade‑offs to guide thoughtful implementation and decision‑making.

Summary and Key Points: As this model continues to evolve, several core ideas clarify what it offers, what it requires, and where its limitations remain.

1. Hybrid rehabilitation is a delivery model that combines traditional, in‑person rehabilitation with remote, digital, or home‑based components.
2. Hybrid rehabilitation has the potential to reduce healthcare costs and improve outcomes, while reducing barriers common to traditional care methods.
3. Advanced training is recommended to improve skills that optimize digital communication.
4. Quality hybrid rehabilitation depends on reliable technology, technology infrastructure and digital literacy.
5. Workflow will be different and will require strong system-level support.
6. There are both strengths and weaknesses to hybrid rehabilitation; some of the weaknesses we haven’t fully vetted.

Layperson Summary

Hybrid rehabilitation blends in‑person visits with digital or at‑home care, giving people more options for receiving support. It can lower costs, improve results, and remove common barriers such as travel and scheduling challenges. To work well, though, it requires clinicians skilled in digital communication, reliable technology that patients can easily use, and robust systems behind the scenes to keep everything running smoothly. Like any care model, it has clear advantages and some drawbacks we’re still learning about, which is why it’s important to understand both sides as this approach continues to grow.

References

1. Harvey D, White S, Reid D, Cook C. A consensus-based agreement on a definition of a process variable: findings from a New Zealand nominal group technique study. BMC Health Serv Res. 2024 Nov 16;24(1):1416.
2. Harvey D, White S, Reid D, Cook C. Patient perspectives of process variables in musculoskeletal care pathways. Musculoskelet Sci Pract. 2025 Apr;76:103287.
3. Jenkins TO, Edwards GD, Patel S, Nolan CM, et al. Feasibility of a real‑world digital hybrid pulmonary rehabilitation model using a smartphone app. ERJ Open Res. 2024;10(1):00000.
4. Pritchard R, et al. Technology‑enabled hybrid cardiac rehabilitation: Qualitative study of healthcare professional and patient perspectives. PLoS One. 2025;20(2):e0000000.
5. Tousignant-Laflamme Y, Christopher S, Clewley D, Ledbetter L, Cook CJ, Cook CE. Does shared decision making results in better health related outcomes for individuals with painful musculoskeletal disorders? A systematic review. J Man Manip Ther. 2017 Jul;25(3):144-150.
6. Sanders ARJ, Bensing JM, Magnée T, Verhaak P, de Wit NJ. The effectiveness of shared decision-making followed by positive reinforcement on physical disability in the long-term follow-up of patients with nonspecific low back pain in primary care: a clustered randomised controlled trial. BMC Fam Pract. 2018 Jun 28;19(1):102.
7. Sanders ARJ, de Wit NJ, Zuithoff NPA, van Dulmen S. The effect of shared decision-making on recovery from non-chronic aspecific low back pain in primary care; a post-hoc analysis from the patient, physician and observer perspectives. BMC Prim Care. 2022 Feb 2;23(1):22.
8. Bowen E, Nayfe R, Milburn N, Mayo H, Reid MC, Fraenkel L, Weiner D, Halm EA, Makris UE. Do Decision Aids Benefit Patients with Chronic Musculoskeletal Pain? A Systematic Review. Pain Med. 2020 May 1;21(5):951-969.
9. Patel S, Ngunjiri A, Hee SW, Yang Y, Brown S, Friede T, et al. Primum non nocere: shared informed decision making in low back pain–a pilot cluster randomised trial. BMC musculoskeletal disorders [Internet]. BioMed Central; 2014 [cited 2016 Sep 26];15:282.
10. Dosbaba F, Senkyr V, Vlazna D, et al. Comparison of hybrid guided home-based and outpatient rehabilitation in patients with chronic low back pain: A randomized controlled trial. J Bodyw Mov Ther. 2025 Dec;45:110-118.
11. Centers for Medicare & Medicaid Services. ACCESS Model. CMS Innovation Center. https://www.cms.gov/priorities/innovation/innovation-models/access. . Accessed March 2, 2026.
12. Kemp M, Rising KL, Laynor G, Miao J, Worster B, Chang AM, Monick AJ, Guth A, Esteves Camacho T, McIntosh K, Amadio G, Shughart L, Hsiao T, Leader AE. Barriers to telehealth uptake and use: a scoping review. JAMIA Open. 2025 Mar 19;8(2):ooaf019.
13. Gilanyi YL, Shah B, Cashin AG, et al. Barriers and enablers to exercise adherence in people with nonspecific chronic low back pain: a systematic review of qualitative evidence. Pain. 2024 Oct 1;165(10):2200-2214.