Integrated Patient-Centered Care in Chronic Critical Illness (IP4CI)

For patients, the transition between acute and post-acute care is rife with risk. Even with modern electronic medical records and responsible clinicians who seek to collaborate with each other, information can be lost or misunderstood, patients can decompensate and setbacks are common. Particularly challenging is coordination of care amongst patients who are chronically critically ill. Patients who have required long stays in the intensive care unit, or who require continued advanced therapies (mechanical ventilation, etc.) upon discharge, often bounce between acute hospitals and post-acute facilities. These patients are frequently readmitted to acute care hospitals within days of discharge, never recovering enough to resume outpatient-based care. Traditional care coordination models fail to help quarterback their complicated care. At Brigham and Women's Hospital, patients who had spent time in the medical intensive care unit and who were subsequently discharged to long-term acute care rehab had a 30-day readmission rate of 40 percent. This was viewed as unacceptably high and the institution launched a pilot to improve peri- and post-discharge care in this population.