PS2-23: Reducing Rehospitalization in Survivors of Critical Illness: Description of a Novel Interventional Strategy.
Clin Med Res. 2011 Nov;9(3-4):157
Authors: Jones S
Background/Aims Older patients who survive a critical illness are at increased risk for mortality and rehospitalization. Ten percent of ICU survivors discharged to home are rehospitalized within a week, and nearly one-third are readmitted within 180 days. Contributors to these negative outcomes may include complex discharge plans, unrecognized ICU-associated illnesses and separation of inpatient and outpatient medicine through shorter outpatient visits and the hospitalist movement. These factors contribute to the challenges of care transitions and further limit the care coordination of the ICU survivor with complex medical problems. The purpose of the project is to pilot a model of transitional care for older ICU survivors. We propose an innovative model of transitional care for older ICU survivors that has the potential to reduce rehospitalization rates, improve morbidity and decrease risk of mortality. Methods We will target patients 55 years of age or older who have survived a critical illness in the medical ICU and are to be discharged home. We will exclude patients who are unwilling or unable to assume patient responsibilities. Patients (and caregivers) will be empowered through the support of a transitional coach who encourages the patient and caregiver to have a more active role in the health of the patient. Such efforts include medication reconciliation, identification of patient-selected goals, and education about self-management and communication of medical issues. The ICU Survivors Follow-up Care Clinic will be created to address ICU-specific issues that we believe may contribute to the negative outcomes of critical illness. Through these two interventions, we will create a detailed care plan and deliver a coordinated handoff to the primary care physician. Results The project will be evaluated for feasibility and effectiveness using the RE-AIM framework. We will conduct cost analysis to determine the long term sustainability of the program. Conclusions Older ICU survivors are at risk of hospital readmissions for many reasons. A novel program that integrates patient empowerment and early recognition and follow-up of ICU associated illness may impact these negative outcomes.
PMID: 22090566 [PubMed - as supplied by publisher]