Interdisciplinary rehabilitation program

The program includes direct service provision, education, and consultations to achieve the predicted outcomes of the persons served.

Information about the scope and value of services is shared with the persons served, the general public, and other relevant stakeholders. The strategies utilized to achieve the predicted outcomes of each person served determine whether the individual program is single discipline or an interdisciplinary service.

A Single Discipline Outpatient Medical Rehabilitation Program focuses on meeting the needs of persons served who require services by a professional with a health-related degree who can address the assessed needs of the person served. The World Health Organization's WHO definition of rehabilitation describes the importance of providing interventions directed towards interaction within the individual's environment , to facilitate participation in meaningful activities [ 21 ].

To date, few studies investigated interventions for patients recovering from critical illness after home discharge, and reported poor attendance of outpatient exercise programs. Travel time and patients' lack of motivation were identified as reasons for non-attendance [ 22 — 24 ]. If primary care rehabilitation specialists such as physical therapists PTs , occupational therapists OTs and dietitians DTs can provide early home-based interventions for patients with functional impairments related to PICS, this might increase adherence and satisfaction, decrease the chance of hospital readmissions, and cut healthcare costs [ 12 , 23 , 25 — 27 ].

Care provided within an interprofessional network has shown to increase professional expertise and improve the quality of care [ 28 , 29 ]. While expert recommendations for home-based, PT-led interventions for survivors of critical illness have been published [ 26 , 30 , 31 ], feasibility of such interventions within the primary care setting is yet to be investigated.

Therefore, the aim of this study was to investigate the feasibility of an interdisciplinary home-based intervention for patients with new or worsened impairments within one of the domains of PICS, initiated immediately after hospital discharge and targeting physical recovery and self-management in comparison to patients receiving usual care. A mixed method, non-randomized, prospective pilot feasibility study was undertaken with a 6-month follow up and a total study duration of 22 months.

Group allocation was based on convenience sampling; participants received the intervention if they lived in an area covered by REACH-therapists, unless they preferred otherwise i.

In line with the pilot feasibility character of the study, no a priori sample size calculations were conducted [ 32 ]. Participants were recruited from 2 university and 5 general hospitals in the Amsterdam area, the Netherlands.

Indication for PT was determined according to the hospitals' protocols for referral, i. Eligible patients were identified by ICU-PTs and after verbal permission was obtained, contacted by telephone by the primary investigator MM within 2 days after hospital discharge.

Once oral consent was obtained, a home visit was planned. First, CoP members from different fields of expertise provided training on the presentation and potential interventions for the different facets of PICS. Professionals within the REACH-network received extensive training with regards to the application of this concept of health in their daily practice, allowing for individualized, tailor-made treatment programs. Regular online CoP meetings facilitated peer-to-peer learning and interdisciplinary collaboration.

The PT interventions started within one week after hospital discharge, initially provided in the home situation of the patient and continuing in the nearby PT practice as soon as their physical condition allowed.

DT interventions were targeted towards optimization of protein intake, according to the Dutch guidelines for malnutrition: 1. If any of these questions were answered with yes, OTs were consulted Additional file 1 : OT screening protocol. OT interventions addressed problems with fatigue and insight in physical capacity, education on cognitive functioning in daily activities and self-management.

All REACH professionals were trained to regularly check for problems within other PICS domains but outside of the scope of their profession—such as psychological problems or worsening medical conditions—and informed general practitioners GPs when required.

PT started with functional exercises aimed at improving ability in ADL and gradually progressive resistance training to increase muscle strength. Interventions targeting exercise capacity progressed from functional, home-based training to in-practice aerobic training. Aerobic capacity was trained by first increasing the duration of the activity before increasing the intensity. The protocol identified 3 rehabilitation phases: 1 the acute home phase, 2 the subacute training phase at the PT clinic and 3 the evaluation long-term follow up phase.

Progression between phases was left to the PTs professional judgment. Frequency of sessions averaged 2 half hour sessions per week in phase 1 and to min sessions twice a week in phase 2. In phase 3 participants often trained independently with irregularly scheduled supervised exercise sessions, as deemed necessary. The total duration of the REACH intervention was not specified a priori as decision-making depended on individual patient needs.

As no formal care pathway exists in the Netherlands for patients recovering from critical illness, we considered any participant who did not receive the REACH intervention, to be eligible for the usual care group. Professionals involved in the usual care provision were not part of the REACH-network and did not receive additional training on interventions targeting PICS and application of the positive health concept.

Some patients in the usual care group may not have received interventions from allied health professionals at all, dependent on their own preferences and the organization of health care. Primary feasibility outcomes were safety and optimal dose of the REACH program, patient and professional satisfaction, adherence to treatment and protocol, need for interdisciplinary referral and health care usage.

Secondary outcomes were functional exercise capacity, self-perceived health status, health-related quality of life HRQoL , return to work RTW , prevalence of psychological problems including symptoms of PTSD and risk of undernutrition at time of hospital discharge. Data on safety and optimal dose of the intervention were collected throughout the duration of the study by tracking adverse events and protocol deviations.

The PREM Physical Therapy is developed to measure patient experienced quality of the PT and the interventions received, estimating a global perceived effect and a net promotor score NPS , which is calculated from the 0—10 score given to the question 'Would you recommend your PT to others with similar health problems?

The NPS is the derived result from the percentage promotors minus the percentage detractors. Data on professional satisfaction and adherence to protocol were collected through a mixed-method approach using an online survey and a focus group session among REACH professionals, conducted at the end of the study.

Information on referral need DT and OT was assessed as follows: DT need was assessed counting all cases with risk of undernutrition at time of hospital discharge and OT need was assessed at 3- and at 6-months after discharge by counting the cases applicable for OT based on the outcome of the screening protocol Additional file 1.

Data on health care usage were collected at 3- and 6-months after hospital discharge, using a self-reported questionnaire from a prior ICU follow-up study [ 40 ]. Physical measurements conducted through home visits and data collection of self-perceived health status, HRQoL and psychological status GPS were conducted at three timepoints: 1—2 weeks T0 , 3 months T1 and 6 months T2 after hospital discharge.

Functional exercise capacity was measured with the two-minute step test TMST, [ 41 ]. Before testing, participants' vital signs were assessed by monitoring resting heart rate RHR blood pressure BP and oxygen saturation SaO2 to determine safety and feasibility of test execution. Other contra-indications for test execution were chronic heart failure, presence of chest pain, dizziness, wounds under the foot or inability to raise the knee to the height halfway between the iliac crest and the patella.

Self-perceived health status was assessed asking the participants to rate their health on a numeric rating scale NRS ranging from 0 very bad to 10 excellent.

Return to work RTW data were collected via a self-reported questionnaire administered at 3- and 6 months [ 40 ]. This tool categorizes nutrition status based on involuntary weight loss, upper arm circumference, appetite, and physical function in three categories: undernutrition red , risk of undernutrition orange and no undernutrition green [ 35 ]. Prevalence of traumatic symptoms was determined at all 3 timepoints using the Global Psychotrauma Screen GPS , a item questionnaire designed to screen for a broad scope of potential trauma-related outcomes.

A sum score of the remaining 17 questions provides a total score for GPS symptoms [ 47 ]. Due to the feasibility design of this study, no formal hypotheses testing on within and between group change over time were conducted—as the study was underpowered to test for effectiveness [ 32 ].

For the secondary clinical outcomes, descriptive statistics at the 3 timepoints were calculated and converted to percentage of predicted values for outcomes where normative values exist. Qualitative data obtained through the focus group session were transcribed verbatim and combined with qualitative survey data.

Further coding and thematic analysis of qualitative data took place and results are reported narratively. Written informed consent was obtained from all participants in line with the Good Clinical Practice directives. In total, 74 survivors of critical illness were referred for participation in the study, of which 16 were excluded because they were transferred to a long-term rehabilitation facility before home discharge, leaving 58 eligible participants.

Application of the in- and exclusion criteria left a total of 43 participants, 19 participants were included in the intervention group and 24 in the usual care group. In each group 2 participants dropped out during the study due to an acute new medical event, unrelated to the intervention, requiring admission to hospital, rehabilitation- or palliative care facility. This resulted in a 6-month follow-up of Physical measurements continued as soon as protocols were put in place respecting social distancing and hygiene.

This resulted in some missing data but no participant drop-out Fig. Participant demographic and medical characteristics were similar between groups, except for age and hospital length of stay LOS ; participants in the intervention group were older than in the usual care group median [IQR] age 63 [9] vs 54 [23], p 0.

No intervention related adverse events occurred and participants showed compliance to the treatment, as evaluated by the PTs providing the intervention: none of the patients included in the REACH group ceased treatment against the advice of the professional. REACH-PTs recognized that the treatment approach within the interdisciplinary network resulted in motivated patients showing high adherence to treatment, but identified challenges related to balancing care provision considering the patient's physical and mental capacity throughout the different stages of recovery.

Evaluation of satisfaction among REACH professionals manifested the following positive feedback: applying the broader concept of health 'positive health' facilitated patient-centered care, in turn increasing patient satisfaction:.

I notice that [Positive health] is increasingly benefiting my way of communicating with patients [.. I notice patients are very satisfied The continuous professional development experienced by professionals within the interdisciplinary network, resulting from online meetings and training sessions, social media channels, discussion fora and monthly newsletters, increased awareness towards problems beyond the professional scope and led to changing one's daily practice:.

That meeting where we received information about nutrition and training opened my eyes! Additionally, professionals experienced urgency in continuance of their professional development considering the complexity and heterogeneity of PICS, suggesting the network to be expanded with professionals from other disciplines, such as psychology and speech and language therapy SLT.

Similar emphasis was given to the need to expand the REACH network to a larger geographical area and ultimately to have nationwide coverage. Being ready to provide fitting interventions for patients recovering from COVID and being able to share knowledge and expertise to colleagues through national webinars was seen as a powerful opportunity:. How great is it I really hope that we can take part in future research projects and continue meeting like this FT 6.

Thematic analysis revealed professional challenges regarding the delivery of optimal rehabilitation interventions for patients with PICS. PTs identified the need for further validation of functional aerobic capacity tests for patients with PICS, such as cardio-pulmonary exercise testing CPET as soon as safely possible to establish training parameters and objectively evaluate an increase in exercise capacity.

For patients for whom health insurance did not—or only limitedly—cover the expenses of the PT interventions, professionals often had to make difficult choices: to shorten the program or to provide sessions free of charge. You can design an intervention program with a desired frequency and for a desired duration but with limited coverage, you run out really quickly.

Treatment is so dependent on individual circumstances and that makes it difficult. This patient I have, for example I have let him come for 2 additional months without letting him Evaluating the application of the positive health concept, professionals indicated that the provided conversational tools were somewhat complicated and time-consuming in daily use, especially when met with patients with limited health literacy.

The percentage of participants reporting hospital readmissions acute and elective was higher in the intervention group compared to the usual care group at both 3- and 6-month follow up The percentage of participants having planned hospital check-ups was initially similar between groups 3 months: REACH: The need to refer to OT seemed to increase over time as the number of sessions and percentage of participants receiving OT increased in the REACH group between 3- and the 6-month follow up , while the percentage of participants needing DT interventions decreased somewhat over time REACH: Visits of nursing practitioners were more frequent in the first 3 months after hospital discharge REACH: visits and usual care: 98 visits compared to the period between 3—6 months REACH: 30 visits versus usual care: 27 visits.

SLTs were not seen by anyone in the REACH group, and only 3 visits were reported by 1 participant in the usual care group in the period between 3—6 months. Appointments with psychologists occurred more often in the usual care group in the first 3 months REACH: Functional exercise capacity, measured with the TMST, was established in Reasons for non-completion were unstable vital signs elevated resting systolic or diastolic blood pressure or heart rate or severe physical deconditioning, making the safe execution of the test impossible.

Data show a similar perceived improved health status between timepoints in both groups. For HRQoL, baseline physical and mental component scores PCS and MCS for both groups are well below normative values and show a comparable recovery at 3- and 6 months, with minor differences observed between groups.

Notably, neither group reaches normative values for PCS at 6 months [ 45 ]. Of the participants who were employed prior to their ICU admission, At 6 months Our results show that collaboration within an interprofessional network consisting of hospital-based and primary care professionals, is a feasible method to provide rehabilitation interventions across the care continuum for survivors of critical illness.

Commonly, hospital-based follow-up clinics are set up to identify aftercare needs for patients with PICS, but the timing of the first appointment is often delayed due to functional impairments patients might experience immediately after discharge [ 27 ]. As recommendations for rehabilitation interventions in the primary care setting are lacking [ 14 ], we believe our study might serve as an example for the implementation of healthcare interventions for patients with PICS-related symptoms across the care continuum, adding to the experience of a seamless transition from hospital to home.

Participants in the REACH group showed high motivation and adherence to treatment and reported higher satisfaction with PT treatment, when compared to the usual care group. This is contrary to findings of previous studies, which identified the heterogeneity of the population needing rehabilitation interventions after critical illness as a barrier for intervention adherence [ 22 , 23 , 25 , 27 , 49 ].

The extensive and long-term impairments of patients with PICS, potentially amplifying each other across health domains [ 50 ] could be explanatory for the fact that previous trials did not find significant differences in outcomes when compared to a control group. As trials need strict protocols and a 'one size fits all' design does not meet the needs of patients with PICS, different study designs and different types of interventions need to be explored.

For this reason, the REACH intervention was characterized by a flexible, patient-centered, and tailored approach, founded in the principle of delivering the right care, at the right place, at the right time and by the right professional [ 51 ]. Providing the early interventions in the patients' homes could be another explanation for the low drop-out rate and high adherence to treatment in the REACH group, contrary to findings in studies with a larger, but similar population.

Denehy et al. Similarly, in a study by Berney et al. Poor attendance and low adherence were explained by travel distance, poor social support and limited available time [ 22 ]. Our study shows that an individualized, home-based rehabilitation intervention increases patient adherence and satisfaction. Early home-based interventions are also likely to contribute to patient motivation and generally improve the transition from hospital to home [ 20 , 27 , 50 ]. In this study we defined PICS as 'new or worsening symptoms in the physical, psychological or cognitive health domain, unrelated to the initial admission diagnosis or underlying conditions, at time of ICU- or hospital discharge'.

A definition founded in the umbrella term postulated by the Society of Critical Care Medicine in [ 2 ] and applied in recent publications in absence of alternative diagnostic tools [ 33 , 52 , 53 ]. Clinical tools are needed to identify the presence of PICS and the extent of PICS-related disability, and although recently the development and validation of some tools have been investigated, further studies are urgently needed for better definition and understanding of PICS [ 54 — 58 ].

Working with the limitation of a not clearly defined population, we designed a patient-centered intervention embedded within an interdisciplinary collaborative network addressing the complex cluster of problems in patients with PICS conform recent recommendations [ 12 , 33 , 54 ]. Professionals within the REACH network showed great enthusiasm towards the opportunities for professional development, even on topics which were outside the scope of their discipline. Our finding is in line with current literature, stating extreme loss of muscle mass in critically ill patients while reversal of the inflammatory, catabolic state takes time and effort [ 19 , 59 , 60 ].

An explanation for this could be the early start of PT interventions, which in most cases combined with DT consults contributed to an already full rehabilitation schedule for patients. Balancing care provision while preventing to overload patients who are generally characterized by low physical and mental capacity, was a continuing challenge for professionals.

Especially if, as recommended by REACH professionals, the interdisciplinary network is expanded with representatives from other disciplines such as psychologists and SLTs, the timing and intensity of the different consultations need to be reviewed considering individual rehabilitation goals. An interdisciplinary team is based in the same facility and works toward the same goals developed after a comprehensive evaluation.

The treatment approach allows for functional recovery through musculoskeletal conditioning, cognitive-behavior therapy CBT , relaxation techniques, and pain medication tapering. Vocational education is a component of many programs. The interdisciplinary approach stresses seamless communication between team members, daily communication, and weekly team meetings to discuss progress and barriers to recovery.

It is time intensive and requires a high level of staffing for the brief period minimum of 3 weeks that patients participate in the program.

Multidisciplinary treatment involves multiple clinicians who are concurrently treating the patient, but often without a coordinated discussion of the treatment plan, and may not have similar treatment philosophies. There is limited opportunity for integrated communication with this approach. Multidisciplinary treatment does not tend to involve a brief, intense period of treatment, and may go on indefinitely with variable levels of treatment and support provided to the patient.

The core of an interdisciplinary program is a skilled team of clinicians. This team typically includes a physician educated in pain rehabilitation, a psychologist trained in CBT, counselors, case managers, and physical and occupational therapists. Additional team members can include nurses, psychiatrists, and biofeedback specialists. Vocational rehabilitation counselors, particularly for programs designed to assist with return to work following an industrial injury, are an integral part of the team.

There are a small number of inpatient programs throughout the United States, but a larger number is outpatient based. Literature shows many variations of multidisciplinary or interdisciplinary care. A systematic review showed that daily intensive programs with more than hours of therapy were superior in showing improvements in pain, function, and vocational outcomes compared with less intensive programs.

Because many patients have musculoskeletal impairments and have limited ability to be fully functional, patients are guided individually or in a group setting through progressive exercises to reverse the effects of deconditioning. Using the principles of CBT to learn adaptive pain coping strategies, they are taught self-management skills to manage any concomitant mood disorders that may be present, as well as decreasing avoidant behaviors secondary to fear of pain.

Decreasing dependence on habit-forming medications such as opioids and benzodiazepines is another key feature of such programs. Patients typically taper use of medications while they gain self-management skills, enhancing their confidence that they can cope with increased activity with less use and without a significant worsening of their symptoms. The average patient usually presents to an interdisciplinary pain clinic years after being diagnosed with chronic pain.

Multiple efforts at managing their pain have been attempted, including medications, surgeries, physical therapy, aquatic therapy, spinal and joint steroid injections, nerve ablation procedures, dorsal column stimulator placement, intrathecal pump placement, chiropractic care, massage therapy, and acupuncture.