The RECOVER Program — a Toronto Grace and UHN Partnership

Pictured above: The Grace UHN-Recover Interprofessional Team

​By: Gerry Condotta

The RECOVER Program, is a new and innovative collaboration between The Salvation Army Toronto Grace Health Centre (TGHC) and the University Health Network's (UHN) Toronto General Hospital (TGH). The Program, an international first, offers a novel continuum of care pathway for patients and families after an episode of critical illness. It is designed to address care gaps, and challenges related to care transitions for patients moving from post-Intensive Care Unit (ICU), through inpatient rehabilitation, to follow-up at home and in the community. The RECOVER Program will help to ensure that post-ICU patients and their family caregivers enjoy integrated care across a seamless, health care continuum pathway. The goal of The Program is to improve patient and family outcomes by decreasing the necessity for hospital readmission, and improving long-term functional independence, mental health and quality of life.  

Two and half years ago Linda Flockhart, clinical director at TGH, was instrumental in steering The RECOVER Program towards the TGHC. Linda approached Jake Tran, then executive director of programs at TGHC, to discuss admitting post-ICU cardiology patients for slow-pace rehabilitation. Acknowledged as a leader in low-tolerance, slow-pace rehabilitation, the TGHC has an extensive and well-developed program, and a team of knowledgeable and experienced interprofessional health care staff equipped to address the needs of complex continuing care and post-acute care patients.

At that time, Dr. Margaret Herridge, a colleague of Linda Flockhart at TGH, was working to develop a National Recover Program for post-ICU patients and families, and was actively seeking to partner with a rehabilitation facility that could accommodate complex post-ICU patients. Given that Jake was receptive to Linda's proposal, Linda thought Jake might be interested in listening to a presentation by Dr. Herridge.

After Dr. Herridge presented her research with all the information about starting The RECOVER Program for post-ICU patients, Jake accepted her proposal to partner with TGH. "When Jake said, 'We would love to work with you.' I was shocked," Dr. Herridge said, "mainly because I felt he was the first person outside our own institution and with a rehabilitation perspective to fully appreciate the potential importance of our program."

Dr. Herridge had previously approached other rehabilitation facilities with her idea. Although all saw the importance of The RECOVER Program and understood it would represent a health care innovation, they were ultimately unwilling to partner with TGH since they were concerned about their institution's ability to care for these complex patients.

The RECOVER Program has been designed as a three-phase project. The first phase of the program (2007–14) involved conducting a national multi-centred research study to gain a detailed understanding of the functional, cognitive, and quality-of-life outcomes of patients and families after critical illness. For the past 22 years, Dr. Herridge, a senior scientist, respirologist, and intensivist (a physician who specializes in the care of critically ill patients in the intensive care unit), has been the director of the UHN's ICU outcomes group. This post-ICU outcomes group led an international research team that studied post-ICU patients. Their findings showed that patients who survive ICU are left with numerous morbidities, including neuromuscular and neurocognitive dysfunction, serious mood disorders, and diverse medical problems. Part of the work Dr. Herridge and her team have been doing at TGH involves helping the community-at-large understand that patients, as a result of having a critical illness (or sometimes as a result of treatment), acquire many complex medical conditions, and these conditions are possibly not being addressed after the patients leave the ICU. These new or worsening ICU morbidities can contribute to, among other things, long-term disability, a requirement for significantly more healthcare treatment, or an inability to live independently or return to work. All of these contribute to a compromised quality of life.

Obviously, suffering a critical illness is traumatic for the patient, but the impact of a serious illness has impacts beyond the patient alone. The UHN's ICU-outcomes group recognized this and began to study the effect that critical illness can have on patients' families. "This helped us recognize," says Dr. Herridge, "that a critical illness episode suffered by a patient can also traumatize the family, who develop their own severe mood disorders that are largely unrecognized and untreated. We felt strongly that our RECOVER Program must also address the needs of the family."

Further analysis of the data collected by their ICU outcomes group confirmed the necessity for creating a care pathway beyond the ICU. Early mobilization in the ICU has been shown to improve outcomes, but Dr. Herridge and her team noted that post-acute care after ICU discharge is limited. "The patient is not moving forward," said Dr. Herridge. "Patients have a tendency to languish on the hospital ward for weeks while we try to find them an appropriate destination." The post-acute care provided is often inadequate, since it does not address the medical complexities of these high-risk groups and rehabilitation is only intermittently provided.

One of those appropriate destinations for post-ICU patients is the TGHC. Dr. Herridge and her team did a pilot project and found that only 30 percent of post-ICU patients at TGH were well enough to be in a fast-pace rehabilitation environment. Seventy percent of post-ICU patients require the low-duration, slow-pace rehabilitation that the TGHC provides. "That is a significant majority," said Dr. Herridge, "and going forward we will likely need more rehabilitation facilities like the TGHC to meet the needs of our ageing post-ICU population."

Phase two and three of The RECOVER Program will involve collaborating with TGHC. The partnership between TGHC and The UHN RECOVER Program will promote care-planning and the appropriate accommodation of patients (including the frail elderly) in inpatient rehabilitation settings after their discharge (<7 days) from ICU. It is anticipated that this will decrease acute care bed utilization (length of stay), as well as overall acute hospital costs and downstream healthcare utilization. Discharged post-ICU patients will spend more time in an appropriate inpatient setting, benefitting from the TGHC's Complex Continuing Care Post-Acute Care Rehabilitation programs.

At the TGHC, the ICU team from TGH will participate in the weekly case conference, lending their perspectives as intensivists, psychiatrists, and primary care physicians, with the goal to educate the TGHC team about the patient histories and so to help provide continuity in the patient's rehabilitation journey. The Program will also provide mental health intervention for patients and families, as well as a weekly mindfulness program. The members of the TGH ICU and TGHC's interprofessional health care teams will mirror each other (pharmacy, occupational therapist, physiotherapist, speech-language pathologist, physicians) in transition-care planning in order to ensure a consistent interprofessional health care team approach to patient-centred care. This approach to care will require the interprofessional health care teams to share data and communicate effectively to ensure integrative transitional-care planning occurs after an ICU discharge, during inpatient rehabilitation, as well as while transitioning back to the community or home. The RECOVER Program will follow the patient/family for one year after discharge from the TGHC's rehabilitation program, and will ensure that patients are given appropriate resources and close follow-up through the TGHC's outpatient clinic. Patients who live far away or who have difficulty accessing the outpatient clinic at the TGHC will be connected with the proper resources in their community and offered offsite or home-based follow-up by the team.

The RECOVER Program is both a clinical and research program. The research component will address healthcare gaps across the critical-illness and recovery continuum. It will focus on three key elements: the coordination of continuity of care from ICU to the community for patients and their families; the examination of the interprofessional health care team-based approach to complex care delivery and the effectiveness of early post-ICU inpatient rehabilitation and one-year follow-up in the community or home; and the education (knowledge transfer) of patients, families, members of the health care team, policy makers, and the public.

It is important to help the patient and family to understand their medical journey after a critical illness. "Post-ICU patients," says Dr. Herridge, "and their families may have a new normal. The intent of the project is to help them recover from the medical issues acquired during their critical illness. The truth is, we are better at saving lives in the ICU, but in doing so, we create other morbidities and disabilities. We will educate the patient and family about the new health trajectory they occupy after critical illness, teach self-efficacy and empowerment. We will provide the patient and family with resources, but will actively encourage self-advocacy and instill confidence in their ability to exert control over their lives and any disability they have acquired. We will reintegrate the patient into the community and close the loop on their care. By including a primary care physician in the patient's medical journey from the ICU, we will use their insights to augment education of primary care physicians about the long-term sequelae of critical illness and the complex needs of post-ICU patients and their families."

The public and patients might assume that a program like RECOVER already exists, because they believe that when a patient enters a health care facility they are treated fully and that there is in place a continuity of care protocol to manage the patient's recovery through to the community. Dr. Herridge believes that this assumption has been a barrier when seeking funds from granting agencies also, since those agencies assume, too, that a care pathway for post-ICU patients already exists. Currently, there are no care models, nationally or internationally, that extend from ICU through inpatient rehabilitation to the community and that integrate interprofessional health care team-based care to address complex physical and mental health needs and to engage patients and families in post-ICU care planning.

The reason The RECOVER Program does not exist is because the health care system is compartmentalized. "For example," said Dr. Herridge, "as an intensivist, I would never have occasion to discuss care with the rehabilitation staff after a patient is discharged from the ICU." These are the healthcare gaps Dr. Herridge said, The Program will be addressing. To help bridge these gaps, RECOVER will create an integrated unit, made up of ICU professionals and the members of the interprofessional health care team, two groups who historically have never talked to each other, to support patients and families navigate across healthcare settings with good continuity of care.

Both Dr. Herridge and Jake Tran, President and CEO at TGHC, believe that The RECOVER Program is timely, and that the partnership between TGH and the TGHC is a strong one, able to deliver this innovative patient model of care. Dr. Herridge is indebted to Jake and the TGHC and its staff for the level of commitment they have demonstrated and their early support, which includes a $420,000 research grant to support The RECOVER Program.

This article was originally published here.