Reimagining inpatient cardiac rehabilitation: A world café study of system-level gaps and opportunities

Background Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide. Inpatient cardiac rehabilitation (ICR) is an effective intervention that supports recovery and long-term outcomes, yet it remains underutilized due to low referral and uptake. Given the growing burden of cardiac conditions and the increasing pressures on the healthcare system, accessible and effective ICR is essential. As patient needs evolve, care models must be reassessed to remain relevant, responsive, and patient-centred. Methods A World Café was undertaken to redesign and modernize an ICR program in [Blinded for Review], Canada. The event brought together healthcare providers, researchers, and individuals with lived experience to reflect on the current program and envision an enhanced model of care. Twenty-nine individuals participated in a one-day workshop, including 17 external participants who contributed to discussions and 12 study team members who supported facilitation and logistics. Research presentations informed structured small- and large-group discussions focused on patient needs and strategies for improvement. Discussion notes were analyzed using qualitative descriptive methods. Results Four priority categories were identified: (1) Interprofessional collaboration – fragmented communication across acute care, inpatient rehabilitation, and community settings, with a need for clearer referral pathways and stronger coordination; (2) Education – patients and families required clearer and more accessible information about rehabilitation, self-management, and recovery expectations; (3) Patient-level considerations – cultural, linguistic, psychosocial, caregiver, and accessibility factors were identified as important determinants of engagement and outcomes; and (4) Continuity of care – gaps were noted in discharge planning, outpatient linkage, and post-discharge follow-up. Conclusions Findings highlight the need for a more integrated, standardized, and transition-focused ICR model that strengthens teamwork, aligns education across settings, addresses inequities, and supports smoother transitions across the care continuum. These findings also underscore the importance of ICR in supporting the long-term well-being of patients with CVD and may encourage broader efforts to integrate this service delivery model across the continuum of care. Future research should engage patients in co-design and evaluate the feasibility, acceptability, and impact of the identified strategies on patient experience, care transitions, and outcomes.