The RECOVER Program (REhabilitation and ReCOVERy in Survivors of Critical Illness) is an innovative collaboration between the Toronto Grace Health Centre (TGHC) and the UHN’s Toronto General Hospital (TGH). It provides a novel continuum of care pathway for patients following an episode of critical illness, addressing care gaps and challenges related to care transitions from post-ICU to inpatient rehabilitation, and eventually to follow-up at home and in the community.
Program Objectives
The program aims to improve patient and family outcomes by reducing the need for hospital readmissions and enhancing long-term functional independence, mental health, and quality of life. It promotes care planning and the appropriate accommodation of patients, including the frail elderly, in inpatient rehabilitation settings after discharge from ICU (<7 days).
Collaboration and Care Planning
At the TGHC, the ICU team from TGH participates in weekly case conferences, providing insights from intensivists, psychiatrists, and primary care physicians. This helps educate the TGHC team about patient histories and supports continuity in the patient’s rehabilitation journey.
Interprofessional Team Approach
The interprofessional health care teams from TGH and TGHC mirror each other in transition-care planning. These teams include nurses, pharmacists, occupational therapists, physiotherapists, speech-language pathologists, dietitians, recreation therapists, social workers, respiratory therapists, chaplains, and physicians. They work together to ensure a consistent, patient-centered approach to care.
Rehabilitation and Follow-Up Care
During the rehabilitation phase at the TGHC, the program offers mental health interventions for patients and families, as well as a weekly mindfulness program. The RECOVER Program also follows patients and families for one year after discharge from the TGHC’s rehabilitation program, ensuring they receive appropriate resources and close follow-up through the TGHC’s outpatient clinic.
Community and Remote Support
Patients who live far away or 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.
Research and Education Focus
The RECOVER Program is both a clinical and research program. The research component 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.