A sepsis transition program improves care delivery to sepsis survivors discharged to post-acute care

Introduction: Sepsis survivors discharged to post-acute care facilities are at high risk for mortality and hospital readmission. In this study we compared receipt of transition care practices between patients enrolled in a Sepsis Transition and Recovery (STAR) program and patients receiving usual care. Methods: We conducted a secondary analysis of patients from the IMPACTS randomized trial who were discharged to a post-acute care facility. IMPACTS evaluated the effectiveness of STAR, a post-sepsis transition and recovery program using nurse navigators to deliver best practice post-sepsis care during and after hospitalization. The primary outcome for this secondary analysis was a set of transitional care elements including physical therapy, mental health assessment, speech therapy, follow-up visit within 10 days; documented medication reconciliation, and documentation of end-of-life care preferences. Analyses were conducted under an intention-to-treat approach. Outcome data were described using proportions and compared with chi-squared tests. Results: Of 691 patients enrolled in the IMPACTS trial, 175 (25%) were discharged to post-acute care facilities; 82% of this post-acute care cohort was discharged to skilled nursing, 11% to inpatient rehabilitation and 7% to long-term acute care. Medication reconciliation was documented in under half of patients overall but was nearly twice as frequent in the STAR group compared to the usual care group (62.5% vs 34.5%, p <.01). Few patients received depression screening after discharge although this was much higher among patients in the STAR group compared to usual care (34.1% vs 3.5%, p<.01). Completion of advance directives was also higher in the STAR group (50.0% vs 31.0%, p<.01) compared to the usual care group. Frequency of other care practices such as physical and occupational therapy and early physician followup were similar between STAR and usual care groups. Conclusions: Multiple barriers challenge delivery of transitional care for patients discharged to post-acute care facilities. Our secondary analysis of a clinical trial evaluating a sepsis-specific transition program found that structured transitional care increases the delivery of important care practices for sepsis survivors discharged to post-acute care facilities.