In 2020, UR Medicine Home Care worked with its hospital system to develop an innovative transition-of-care model for patients recovering from critical illness due to COVID-19.
The program seeks to eliminate care barriers by bringing interventions to patients in their homes. This includes nursing care, social work, mental health screening, therapy services, pharmacist evaluation, and evaluation by a critical care physician.
The program is integrated with telemedicine, providing timely screening and collaborative interventions in the patient’s home, optimizing the patient’s participation and social distancing during the pandemic.
One specific goal is to address what’s called Post Intensive Care Syndrome, or PICS. This refers to new or worsening physical, cognitive, or mental health impairments that arise after critical illness and persist beyond the acute-care hospitalization. PICS affects up to 80% of patients surviving acute respiratory failure in intensive care, including patients recovering from COVID-19.
Although the model was created out of necessity, there are opportunities to adapt it to other patient populations and conditions long after the pandemic.
This program was quickly brought to fruition by leveraging a pre-existing, strong working relationship with the agency’s hospital system. Its collaborative focus on care transitions using an interdisciplinary approach is a hallmark of quality and innovation, preventing rehospitalizations and ensuring that patients feel supported throughout their care.