Post-ICU Care Is Transitional Care: A Qualitative Content Analysis of Stakeholder Perspectives on Barriers and Facilitators of Quality Post-ICU Care Delivery

Abstract

RATIONALE: Increased critical illness survivorship due to COVID-19 means feasible, acceptable, scalable models of Post-Intensive Care Syndrome (PICS) care have never been more important. PICS care should help survivors integrate a life-changing event into their identities, adapt to the changes, and resume participation in meaningful roles and activities. Although this is a conceptual model of transition, PICS care has not been examined through a transitional care lens. We engaged diverse stakeholders to describe convergent and divergent perspectives of high quality transitional care delivery for PICS. METHODS: Qualitative content analysis of transcribed semi-structured interviews and focus groups with diverse stakeholders across the post-ICU care continuum in a Western Pennsylvania health system. Pilot-tested interview/focus group guides elicited perceived care needs, and barriers and facilitators to addressing them. Since environmental resources mediate transitions, we probed social determinants of health. We included but did not focus on COVID in recruitment and data collection to optimize generalizability. Five trained coders (backgrounds in geriatrics, critical care, internal medicine and psychology) analyzed transcripts, emphasizing convergence and divergence among stakeholders. We unified codes into themes and checked accuracy and completeness with participants. RESULTS: Results synthesize interviews with critical illness survivors (11), family carers (11), rural primary care, home health and social services providers (20), and focus groups with rural home health providers (2) and interprofessional inpatient providers and healthcare administrators (8). All converged on patients' needs to safely achieve functional independence, in an environment including community support, education and training, and individualized goal elicitation. The most significant divergence involved goals: clinicians focused on functional independence, while survivors and family carers discussed adapting their roles and identities and participating in personally meaningful activities. Major barriers were systemic and echoed transitional care literature: lack of patient or family activation/engagement;absent/inadequate communication;lack of teamwork/collaboration;limited follow-up/monitoring;poor care continuity;and serious service gaps in transitions between providers and across care settings. Facilitators were situation-specific means of addressing barriers (e.g., going above and beyond, hiring a care manager). Participants uniformly viewed social determinants of health (i.e. access, cost, sociopolitical forces) as instrumental to and often dominant in care quality. CONCLUSION: The first “whole continuum” perspective on PICS care fits a conceptual model of transitional care. The next step is the development of an intervention model adapting active ingredients of evidence-based transitional care to the post-ICU context.