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Transition from Acute to Post Acute Care

The Challenge

For patients, the transition between acute and post-acute care can be difficult. And, coordinating care for patients with complex critical illness can be particularly challenging. At BWH, we found that patients who had spent time in the medical intensive care unit and who were subsequently discharged to a long term acute care (LTAC) facility had a 30-day readmission rate of close to 40%. To reduce this readmission rate, we launched a pilot focused on improving peri- and post-discharge care in this population. This pilot became our Integrated Patient-Centered Care for the Complex Critically Ill (IP4CI) program.

Our Solution

The IP4CI program aims to improve the patient-centered nature of care for complex critically ill patients by introducing a continuity team that follows these patients from the Brigham through their hospitalization at the post acute setting of Spaulding Hospital Cambridge (SHC). As part of the intervention, our Brigham continuity team conducts weekly clinical teleconferences with clinicians at SHC, and physician members of our continuity team are available to SHC clinicians 24/7 to discuss urgent issues.

Results to date

The IP4CI program has included over 295 discharges from Brigham and Women's Hospital to SHC over 2.5 years and has reduced the 30-day readmission rate by 25% in this population.

Watch a short video about IP4CI here.


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