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Vanderbilt Studies Value of Virtual Care for ICU Discharges

Analysis  |  By Eric Wicklund  
   October 30, 2023

The health system is using a federal grant to analyze how a virtual care platform can be used to coordinate care after ICU discharge and reduce negative health outcomes.

Vanderbilt University researchers are using a $3.6 million federal grant to explore how health systems can use virtual care to improve care coordination and management after an ICU discharge.

The study, funded by the National Institute on Aging, focuses on post-intensive care syndrome (PICS), which can affect as much as 80% of discharged patients and leads to reduced clinical outcomes, poor quality of life, and rehospitalizations. Researchers led by Leanne Boehm, PhD, RN, ACNS-BC, FCCM, an assistant professor of nursing, will study how hospitals can coordinate care after ICU discharge with primary care physicians to reduce PICS and boost care management.

“Following ICU discharge, patients have problems lasting months to years that often go unaddressed,” Boehm said in a press release. “Primary care providers—and even ICU clinicians taking care of these patients—do not know much about PICS.”

“Only recently have we started to characterize what PICS assessment and management looks like across ICU recovery clinics,” she added. “We’re seeing so much variation in what clinics are doing. This made us wonder which screening intervention elements were the most important in ICU recovery clinics.”

The results of the study could help healthcare organizations develop new strategies for collaborating with PCPs and other resources, including caregivers, to improve the patient’s journey from the hospital to the home or other care site, such as a skilled nursing facility. This includes using virtual care and perhaps remote patient monitoring platforms to track patients more closely and identify and address care gaps before they become serious.

While large health systems often have ICU recovery clinics to help with the transition, smaller and rural health systems often don’t have that resource. The research could not only help ICU recovery centers refine their strategies for connected care, but give those smaller hospitals and networks the guidance they need to improve care and reduce rehospitalizations.

This study follows research recently done by Boehm and others on the value of a telehealth-based multidisciplinary ICU recovery clinic. That research identified the health concerns that accompany an ICU discharge and the value of care coordination and management in reducing negative clinical outcomes.

PICS consists of a variety of physical and mental health problems that remain after critical illness, and affects one-third of patients on ventilators, half of all patients admitted with sepsis, and as many as half of those patients who stay in an ICU for at least a week. One-third to half of those patients develop ICU-acquired dementia, which the NIH now classifies as Alzheimer’s Disease or Related Dementia.

Boehm will be partnering with Carla Sevin, MD, director of Vanderbilt’s ICU Recovery Center and co-chair of the Critical and Acute Illness Recovery Organization’s (CAIRO’s) post-ICU clinic collaborative, and James Jackson, PsyD, director of behavioral health at the ICU Recovery Center, on a telehealth-based model to assess how interdisciplinary teams may be used to transition patients from the hospital and monitor them as they recover from an ICU stay.

“Providers will talk with the patient about their assessment, care plan, what they can expect and the resources to help them in their journey,” Boehm said. The interdisciplinary team, consisting of a physician and/or nurse practitioner, psychologist or psychiatrist, social worker, and pharmacist, “have a multidisciplinary view of ICU-started problems and serve as a bridge in the transition of care from the ICU to their PCP or specialists.”

“Our primary aim is to see if this intervention can improve cognition, mental health, physical function, their social network, and patient activation,” she added.

Eric Wicklund is the associate content manager and senior editor for Innovation, Technology, and Pharma for HealthLeaders.


As many as 80% of patients discharged from the ICU are affected by post-intensive care syndrome (PICS), which can reduce quality of life and lead to rehospitalizations.

Health systems need to develop a strategy for care coordination and management when transitioning patients from the ICU to home or another care site.

Virtual care, and possibly remote patient monitoring, could help health systems improve that care, reducing negative health outcomes and rehospitalizations and improving quality of life for patients and their care teams.

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