5001 – Integrated Patient Centered Care in Chronic Critical Illness: ICU to LTAC
This presentation will discuss an innovative continuity program that was developed by an AMC and an LTACH to address the complex needs of the chronically critically ill patient population. Patients with chronic critical illness represent a high risk, high cost population. This cohort of patients is characterized by long length of stays at both the acute care hospital and at the LTAC. Their illness leaves them with significant functional and emotional impairment. They have an elevated 30-day readmission and six-month mortality rate.
Brigham and Women’s Hospital (BWH) and Spaulding Hospital Cambridge (SHC)’s Integrated Patient Centered Care in Chronic Critical Illness (IP4CI) program focuses on optimizing seamless transitions of care, providing structure for ongoing communication between providers at both institutions and maintaining a focus on achievable goals that match patient values. The continuity team includes representation from both hospitals, including physicians, nursing, case management, and social work. In the six years the IP4CI program has been in existence, this collaborative program has improved patient and family transitions, made positive impact on patient outcomes, and reduced the readmission rate for this complex population of patients.
This presentation will discuss the need for the program and how we initiated the Continuity Program between two hospitals. The presentation will provide a review of the program’s development and evolution through the years, data that shows our impact on patient outcomes over the life of the program, the utilization of telehealth to maintain communication, and a case review of two complex patients who were successfully discharged from LTAC.
1. Participants will be able to identify the complex needs of the chronically critically ill patient population
2. Participants will be able to discuss the impact of a continuity program in preventing readmissions and improving patient outcomes for chronically critically ill patients
3. Participants will be able to develop a continuity program for chronically critically ill patients using telehealth as a tool between hospitals and post-acute care providers