The RECOVER Program

The RECOVER Program (REhabilitation) and ReCOVERy in Surviviors of Critical Illness) is an innovative collaboration between the TGHC and the UHN’s Toronto General Hospital (TGH).  The program offers a novel continuum of care pathway for patients after an episode of critical illness.  It is designed to address care gaps and challenges related to care transitions for patients moving from post-ICU, through inpatient rehabilitation, to follow-up at home and in the community.  The program improves patient and family outcomes by decreasing the necessity for hospital readmission, and improving long-term functional independence, mental health, and quality of life.

The RECOVER Program promotes care-planning and the appropriate accommodation of patients (including the frail elderly) in inpatient rehabilitation settings after their discharge (<7 days) from ICU.  This decreases acute care bed utilization (length of stay), as well as overall acute hospital costs and downstream healthcare utilization.  Discharged post-ICU patients spend more time in an appropriate inpatient setting, benefitting from the TGHC’s Complex Continuing Care and Post Acute Care Rehabilitation programs.

At the TGHC, the ICU team from TGH 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 members of the TGH ICU and the TGHC’s interprofessional health care teams mirror each other (nurses, pharmacists, occupational therapists, physiotherapists, speech-language pathologist, dietitians, recreation therapists, social workers, respiratory therapists, chaplains, physicians) in transition-care planning in order to ensure a consistent interprofessional health care team approach to patient-centred care.  This approach to care requires 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.

During the rehabilitation phase at the TGHC, the program provides mental health intervention for patients and families, as well as a weekly mindfulness program.  The RECOVER Program also follows the patient/family for one-year after discharge from the TGHC’s rehabilitation program, and ensures 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 are 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 addresses healthcare gaps across the critical-illness and recovery continuum.  It focuses 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 healthcare team, policy makers, and the public.