The Need for Continuity of Care in Neurocritical Care and Recovery

Purpose of review After discharge from the Neurological Intensive Care Unit (NICU), patients often have new functional limitations and comorbidities requiring ongoing supportive care. In this review, we discuss the current state across the care continuum and identify opportunities for improvement. Recent findings Patients often transition through multiple care settings after discharge from the NICU. Disposition to SNF (skilled nursing facility) and IRF (inpatient rehabilitation facility) varies significantly based on insurance coverage and geography. Opportunities for improvement in care transitions from the hospital to rehabilitative care include enhanced communication with patients and their caregivers to facilitate optimal rehabilitation location and services for long-term support. Standardized communication tools can reduce medical errors with early discharge planning. Early supported discharge can be considered to provide patients with coordinated community or home-based rehabilitation. Summary After discharge from the NICU, patients need close outpatient follow-up for medication management, prevention, and management of medical and neuropsychiatric complications. Engagement of ICU providers in long-term outpatient follow-up as part of an organized post-ICU recovery clinic could help them learn about long-term patient experience and recovery, influence sensitivity to managing and preventing neuropsychiatric complications, help guide communication with patients and families, and may reduce provider burnout.