UR Medicine Home Care, Hospital Collaborative Addresses Post-Intensive Care Recovery from COVID-19     

Ever heard of PICS, or post-intensive care syndrome?

Clinical professionals with expertise and foresight are doing something about this little-known problem, with home care playing a prominent role for patients who may suffer from lasting and debilitating impairments because of COVID-19, including conditions that could manifest or change long after a patient leaves the hospital.

Working together, UR Medicine Home Care and its hospital system partners have developed a ground-breaking Critical Illness Recovery Program. This integrated program is distinguished not only for its vision addressing PICS but also for its reinforcement of the mutually supportive relationship that ideally exists between hospitals and home care — one reason why the UR Medicine initiative is featured in our grant-funded “Statewide Hospital-Home Care Collaborative for COVID-19 and Beyond.”

What the Research Says

The research supporting this initiative is compelling. Patients discharged from the hospital after acute illness often have profound and long-lasting physical, neurocognitive, and functional impairments. This is especially so for COVID-19. Up to 80% of patients surviving acute respiratory failure in the ICU experience PICS. For these patients, home care can provide a vital support system in coordination with the hospital after the patient arrives home.

Program Design

In response to the needs of these patients, UR Medicine’s hospital and home care partners designed a new set of protocols, providing follow-through with patients from hospitalization to recovery at home. For patients meeting certain criteria, the program includes a standardized, multi-disciplinary screening and referral process using the newly developed protocols and assessment tools which are implemented at key points in the patient’s recovery process at home.

The program includes a standardized 14- and 90-day telehealth visit connecting the patient, his or her family, the home care team, the hospital team, and pharmacists to review how the recovery is progressing and determine if treatment adjustments and/or added interventions are needed.

Together, the team examines prescription drug issues, the need for adjustments in oxygen, influenza or pneumonia vaccines, mental health and neurocognitive concerns, and a range of other possible PICS complications and interventions. The program is uniquely integrated, with the various service settings all playing a role throughout the course of treatment from hospital to home.


HCA is proud to partner with the Healthcare Association of New York State and Iroquois Healthcare Association to feature this program as part of our Collaborative, which is funded by the Mother Cabrini Health Foundation to model hospital and home care partnerships — like this one — while providing education, resources, and technical support.

To learn more, please watch a series of webinars profiling UR Medicine’s program and others on our Collaborative webpage here.