Objective:

To evaluate the implementation of a Telehealth Critical Care Recovery Clinic (CCRC) in improving continuity of care and post-ICU recovery for critically ill patients with neurological injuries.

Background:

Post-ICU patients with neurological injury often experience ongoing physical, emotional, and cognitive challenges after discharge. However, outpatient follow-up is often fragmented and difficult to access. To address these gaps, a telehealth CCRC program was established as an innovative approach to improve recovery and continuity of care by delivering coordinated, multidisciplinary support during patients’ transition back to daily life. 

Design/Methods:

A telehealth CCRC for post-ICU patients was implemented at a tertiary academic center. Eligible patients were identified 30 days post-discharge from the neuroscience ICU (NSICU) and included if their ICU stay exceeded 48 hours, emphasis given to those with major neurosurgical procedures or on mechanical ventilation. Standardized questionnaires (mRS, PHQ-9, GAD-7, QoL) were administered during clinic visits. Descriptive statistics summarized demographics, clinical characteristics, and program engagement for patients seen between 2020 and 2025.

Results:

A total of 77 patients were enrolled and seen by a neurocritical care physician within 60 days post-discharge. The mean age was 57.6 years, and 59.7% were female, with an average ICU length of stay of 8 days and hospital stay of 17 days. Most patients were discharged home, and those who completed questionnaires, mRS scores reflected mild to moderate disability post-discharge. Compared to traditional primary-care follow-up, where less than half of post-ICU patients nationally visit a doctor within 30 days, the CCRC proactively engaged eligible patients ensuring consistent multidisciplinary follow-up. Implementation challenges included staffing changes, limited personal and technical barriers to telehealth.

Conclusions:

The telehealth CCRC demonstrated feasibility and early success in improving continuity of care for post-ICU patients. Neurocritical care follow-up provides valuable continuity and specialized insight into ICU-related patient concerns that primary care physicians may not be equipped to address.