By Jeanie Davis

When a seriously ill patient has not stabilized in the ICU, the next step may be a long-term acute care hospital (LTACH) like Spaulding Hospital Cambridge (MA) — which often is a difficult transition, says Caitlin Ryan, MPH, LICSW, CCM, manager of case management at Spaulding Hospital.

“Very often, these are patients who have a tracheostomy and haven’t been able to come off a ventilator, or they may have end-stage cancer, organ transplants, major neurological diagnosis, or traumatic injury,” Ryan explains. “These patients tend to have multiple comorbid conditions requiring extensive rehabilitation and medication management.”

Patients and their families often are anxious about moving to an unfamiliar facility. “They are worried the staff won’t understand their needs as well as the ICU team,” she notes. “They miss the one on one with the ICU physician, and that loss can be terrifying for many patients.”

Transition Coaching Eases Anxiety

Six years ago, Spaulding joined nearby Brigham and Women’s Hospital (BWH) in creating the Integrated Patient Centered Care in Chronic Critical Illness program to provide a seamless transition of care for these patients and their families.

Transition coaching for patients and families is the first step in dispelling anxiety, Ryan adds. Treatment teams from both hospitals, including the patient’s pulmonary physicians, meet with the patient and family to discuss expectations and goals of care.

“Communication is an essential component of the program,” Ryan says. “Patients wonder, ‘How will they know I’m OK? Will they check on me enough? Will I get my labs quickly enough?’”

When the Brigham team stays in contact with the patient, family, and Spaulding team, the anxiety level decreases dramatically, she adds.

A weekly conference call — typically a video call — helps the family feel in close contact with physicians from both hospitals, says Ryan. “This is especially necessary as the treatment progresses so the families can think about whether to continue treatment.”

The case manager or social worker often participate in the calls. “This provides a really nice connection between everyone involved,” she explains.

The pulmonologists at BWH retain close communication with the Spaulding team, Ryan adds. “We can page them if the patient becomes acutely ill, which helps avoid emergency room visits. These patients are so complicated that if they show up at an ED, they will get admitted. We can avoid all that by consulting with the BWH physician and putting interventions in place.”

If admission is unavoidable, the team can set up a direct admission rather than going through the ED, and avoid the waiting room. If there only is need for an MRI or CT scan, the team can arrange the tests through the BWH ED without admission. Then, the patient can return to the Spaulding LTACH.

Also, the two hospital teams arrange consult appointments so they are timely and appropriate, she adds. “We reduce unnecessary appointments and make sure patients are seen for urgent issues in a timely manner.”

Case Studies

The following are two program success stories:

• One patient, a young woman, had many medical comorbidities throughout her life. As she aged, she was admitted more frequently for respiratory failure, and ultimately required a tracheostomy. At that point, she was doing well enough to go back home — but later developed problems with the tracheostomy and required readmission to Spaulding.

During the six months the patient was at Spaulding, the weekly meetings were integral in discussing the treatment plan, arranging for the BWH pulmonologist to consult onsite at Spaulding and soliciting input from the Spaulding team members. The decision was to switch to a special type of tracheostomy with a design that solved a leakage problem so the patient could go home.

“The family was incredibly scared, and there were a couple of close calls during admission when we thought she might pass away,” says Ryan. “We held weekly conference call meetings with the family and the Brigham team, using video as much as possible for the human element, as it made the family feel more comfortable.”

This patient experiences fewer readmissions than in the past, Ryan reports. “The new tracheostomy and the conferencing made the difference.”

• A patient chronically on ventilator support and dialysis was admitted to Spaulding to resolve one of the issues. In Massachusetts, no facility has the capability for outpatient or skilled nursing care to manage both those conditions. Therefore, he needed inpatient care long term, Ryan explains.

“The family was not ready to give up on this patient, and wanted the patient to come home,” Ryan says. “The team discussed various options, like an outpatient dialysis center and private duty nurse to manage the tracheostomy at home.”

But over time, the family realized the patient was not going to improve, and did not have quality of life. “The family had to see all the options, then over time they began to realize the right decision was palliative care,” she explains. “The patient passed away peacefully.”

“It’s very rewarding when we can help patients and families cope a little bit better and access services that are a little less traditional,” Ryan adds. “Both hospitals get very nice letters from grateful family members.”

Continuity of care is a priority, she adds. “When patients are discharged to a skilled nursing facility or home, the pulmonologist will continue to follow those patients on an outpatient basis to ensure they have the provider they trust the most, which helps avoid unnecessary readmissions.”