Milton King never thought he would make it home again. The Smithfield, RI resident, suffering from thyroid cancer, had a complicated course at Brigham and Women's Hospital after an admission for a collapsed lung. He was on a ventilator, extremely de-conditioned and experiencing delirium. After 3 weeks at the Brigham, he was transferred to Youville Hospital as part of their "Chronically Critically Ill" transfer model.

The clinical team at Youville was prepared for his arrival, having communicated with the Brigham team regarding patient's medical, nursing, respiratory and therapy needs. A social work consult and a family team meeting the first week helped to manage family expectations and set up goals, care plan and ELOS. The Youville clinical team was in action on day one, initiating the weaning process and all therapies. Mr. King was discharged home after a 3-week stay, off the Ventilator, walking and talking.

The transfer process from the acute to post-acute setting wasn't always this way. The idea for the model started in 2005 as the staff from the Thoracic Surgical Intensive Care Unit (TICU) were repeatedly seeing that patients who transferred from the ICU rarely stayed in the receiving facility long, usually needing to return to BWH in the first week. Dr. Shannon McKenna, Medical Director of the TICU, described the impact of the problem to the TICU, "As a result, surgeons became reluctant to permit transfer to an LTAC. This led to a log jam in the ICUs and a great deal of conflict between the intensivists and the individual surgeons."

The staff from Thoracics 11C, led by Dr. McKenna, approached Youville about partnering to improve the transfer process and ultimately the clinical outcomes for these patients. "We chose one LTAC (Youville) to partner with and then began a multidisciplinary process to uncover the reasons for transfers being so unsuccessful. We discovered a few contributors including lack of understanding of what an LTAC could do, poor communication between providers, and unrealistic expectations from patients and families who were used to ICU-level care" quotes McKenna.

The next step was to hold a 'Summit' meeting with key staff from both facilities, where goals were set and educational sessions and tours were organized.

"As a result, we refined our selection process for transfer, set up formal communication channels (multidisciplinary) around the time of transfer, and developed a nursing transitional care plan that reorients nursing activity in the ICU to more closely reflect the patterns of care in an LTAC" says McKenna.

And how is the process working? A review of patient outcomes in 2008 revealed that those TICU patients transferred to Youville had better outcomes than national benchmarks.

As a result of the success of the model, it is now being replicated between the Brigham Cardiac Surgery team and Youville, and at Shaughnessy-Kaplan for patients on the north shore. McKenna cites the value in these terms, "It allows throughput at the hospital, and provides a supportive environment for care of patients who are on a 'slow track'. These patients are not always well served in acute ICUs, as there is a natural tendency to underestimate the potential for recovery of patients who do not wean off the ventilator fairly quickly".

Ann Higgins, Care Coordinator on the TICU, agrees with McKenna. "It has been extremely important and helpful to have built relationships with the post-acute care facilities in our area. It affords us the opportunity to move patients, especially critically ill vent-dependent patients, to an appropriate setting in a timely manner, and know that they are doing well."