Three post-cardiac recovery engagements — patient profiles, in-home ICU augmentation, family interface, and 30/60/90-day outcomes.

A community-dwelling retiree referred at discharge with a fresh median sternotomy and an aggressive beta-blocker titration window. Standard Medicare home-health was insufficient for the visit-density and physician-supervised medication adjustment the case required.

• Patient Profile. 68-year-old male, four-vessel CABG, discharged hospital day 5 on dual-antiplatelet therapy, statin, and beta-blocker titration. Mild pre-op CKD; otherwise baseline functional.
• Intervention. Same-week bedside visit. Sternal-precipitation assessment, daily weights, twice-daily RN check-ins weeks 1–2 (in-person AM, telehealth PM). Physician-supervised beta-blocker titration under Dr. Madyoon through week 4.
• Family Interface. Spouse participated in every home visit week 1 (medication-reconciliation walk-through and sternal precaution education). Weekly written summaries thereafter. Spouse cleared to escalate to RN directly on any weekend concern.
• 30 · 60 · 90 Day Outcomes. Day 30: no readmission; ambulating 200 ft unassisted; sternal incision stable. Day 60: resumed outpatient cardiac rehab, beta-blocker at target dose, no chest pain. Day 90: cleared for return to light work by cardiologist.

A high-utilization patient with a documented pattern of CHF decompensation within the HRRP measurement window. Standard agency home-health had not succeeded; she had been readmitted twice in the prior six months. Family involvement was the load-bearing intervention.

• Patient Profile. 74-year-old female, NYHA Class III at intake, LVEF 30% on recent echo, loop-diuretic dependent, two 30-day readmissions in the prior 6 months (baseline exposure ~33%).
• Intervention. Pre-discharge chart review. Home visit within 36 hours of discharge. Daily Masimo SpO2 + KardiaMobile 6L ECG review through week 4, weekend diuretic adjustment protocol. Diuretic titration in coordination with cardiologist.
• Family Interface. Adult daughter (POA) joined twice-weekly care huddles by phone through week 6. Written home environment checklist delivered week 1 (daily weight log, sodium-restriction inventory, fluid-intake markers). Daughter cleared for at-home diuretic adjustment on RN concurrence.
• 30 · 60 · 90 Day Outcomes. Day 30: zero readmission (vs. baseline 2 readmissions in prior 6 months). Day 60: NYHA Class III → II per cardiology reassessment; six-minute-walk distance up 38%. Day 90: weight stable, no ER visits; daughter reported confidence managing weekend diuretic adjustments independently.

A working-age patient discharged with a freshly implanted ICD and an active DOAC titration window. The clinical question was rhythm stability + anticoagulation in target — and the family question was learning to live around the device without anxiety.

• Patient Profile. 59-year-old male, NSTEMI with reduced LVEF post-MI, single-chamber ICD implanted during index admission for primary prevention, started on apixaban plus antiplatelet therapy. Historically anxious around device alarms.
• Intervention. In-home INR-trend / DOAC adherence coaching. Chest-incision assessment post-device implantation, weekly through week 3. ICD shock-education session with patient and spouse. 8-week rhythm-strip review cadence with KardiaMobile 6L transmissions.
• Family Interface. Spouse present at every week-1 visit (lead-positioning education, magnet-response training). Alarm-response drill run twice in week 2. Spouse cleared to call RN directly on any ICD alert outside business hours.
• 30 · 60 · 90 Day Outcomes. Day 30: no inappropriate shocks; DOAC adherence 100%; INR surrogate markers consistent. Day 60: resumed driving post-cardiologist clearance; device interrogation normal. Day 90: full return to work; device check normal; no further arrhythmia events captured on remote transmissions.