To address persistent barriers to care and to improve the patient recovery process, the Critical Illness Transition and Recovery Program (CI-TRP) at The Ohio State University Wexner Medical Center provides immediate post-hospitalization care, links patients to needed resources and expertise and partners with patients to build a comprehensive, longitudinal recovery plan.
“ICU admissions are often very complex and can create a wide variety of needs that persist when a patient returns home,” says Kyle Stinehart, MD, MPH, a pulmonary and critical care medicine specialist and clinical assistant professor of Internal Medicine in The Ohio State University College of Medicine. “Continuing the connection we established in the hospital not only leads to a better recovery, but it can also reduce long-term health risks and give people a level of support they need.”
Enrollment is generally open-ended, and anyone who’s recovering from life-supportive care is eligible. To identify potential participants, the CI-TRP team works closely with inpatient care teams that interact with the patients and their families every day, including case managers, social workers, physicians and nurse practitioners. People first connect to the program through Jesse Smith, RN, who partners with them to discuss their goals and pinpoint specific needs.
“The transition model we’re using with a dedicated nurse care coordinator is relatively unique, and I think it speaks to a lot of our program’s success,” Dr. Stinehart says. “It’s allowed us to have the reach that we have, and it gives someone an immediate point of contact. So many have said, ‘I don’t know what I would have done if I didn’t have Jesse’s number or if I didn’t have the ability to send Jesse a message.’”
“There’s just so much that comes up after a hospital stay,” Smith says. “I’ve noticed a lot of acute issues that I’m not 100 percent sure they would have mentioned if someone hadn’t called them. We’re not always the team to have an answer to all their questions, but I can definitely get them to the right place.”
Regular CI-TRP providers include pulmonary and critical care physicians, critical care pharmacists, outpatient social workers, physical and occupational therapists and cognitive and behavioral health specialists, but Smith can seamlessly connect to other Ohio State specialists or facilitate referrals to other community resources and providers as needed.
Establishing a partnership
Smith always calls individuals one to two days after they’ve left the hospital.
“I see how they’re doing, check their symptom burden and make sure they have access to things like medical equipment, home health care and medications. And I tell them there are no questions that are out of bounds,” he says.
Smith often coordinates early follow-up support with the CI-TRP social worker who helps with home health care, insurance issues or other concerns.
“All this is before we’ve even seen people in our clinic,” Smith says.
During the first in-person or video clinic visit, the team provides a recap of the hospital stay and reviews any post-hospitalization needs, including tests, imaging and referrals. The team may also screen for ICU-related impairments and health issues, including physical, cognitive and mental health concerns, and an ICU pharmacist is available to answer questions and reconcile medications. Based on screening results, individuals are then connected to other Ohio State specialists or community providers.
For patients with an existing primary care provider, the team sends a comprehensive summary of the hospital stay and follow-up treatment plans. For those without a primary care provider, a referral is made for ongoing management of conditions such as diabetes or hypertension.
Since launching in July 2023 with support from a Patient Care Innovation Award funded by Ohio State University Physicians, Inc., the CI-TRP has completed close to 500 enrollment encounters, and more than 200 people have been seen in the program’s clinic at Ohio State Outpatient Care East.
“We’re now connecting with many of our patients by video visit. I’d say we’re about 70% video, 30% in-person,” Dr. Stinehart says. “With so many in the MICU coming from quite a distance away, video has been a great way to reach people throughout the state, including many patients from more rural areas.”
The length of CI-TRP participation depends on individual needs.
“For someone who’s had a longer ICU stay and needs a higher level of support, we’ll often follow them for up to a year,” Dr. Stinehart says. “Even for people who don’t really have any lingering issues after hospitalization, the program’s still an opportunity to make sure all the right pieces are in place for the best care.”
A model for ICU transitions
Since fine-tuning its own program protocols, the CI-TRP team is looking for ways to collaborate with other ICUs. They recently began partnering with Ohio State’s cardiovascular ICU and are now enrolling people who have been on extracorporeal membrane oxygenation.
“Our goal is to make this kind of transition program a resource for people in ICUs throughout the health system and throughout Ohio. Our model gives patients and their families the opportunity to reflect on a complex hospital stay, learn more about the recovery process and work with our team to build a care plan going forward” Dr. Stinehart says. “Our patients frequently express appreciation for our team’s ability to create a cohesive, accessible care and recovery plan after facing a life-threatening illness, and we’re excited to be able to offer that level of support to everyone who needs it.”
“When people get out of the ICU, they’re ready to get back to their life, and it’s not always that easy,” Smith says. “But we’re here to fill in that care gap and walk with them through recovery.”
Interested in collaborating?
If you’d like to collaborate with or would like more information about Ohio State’s CI-TRP, contact Dr. Stinehart at kyle.stinehart@osumc.edu.
Learn more about innovations in care and research from the Division of Pulmonary, Critical Care and Sleep Medicine.