Identifying Barriers for Successful Discharge Following Cardiac Surgery
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Approximately 15% of patients require prolonged intensive care unit length of stay (prICULOS) after their cardiac operation. We have learned through our previous BSc Med Project “ensuRing patiEntS thrive after PrOloNgED intensive care unit length of stay (RESPOND) following Cardiac Surgery Study” that many of recovering prICULOS patients have persistent chronic pain syndromes, increased frailty, new cognitive and mental health difficulties, ongoing renal issues and decreased quality of life. At present there is no comprehensive process of care to assist these complicated, multi-system patients following hospital discharge. We therefore have identified an unmet process of care needed in these vulnerable patients. The patient-centered medical home (PCMH), is a team-based health care delivery model, led by health care providers, that is intended to provide comprehensive medical care to patients with the goal of obtaining maximized health outcomes. A cornerstone of a PCMH is that is involves the generation of a new model of practice. Using this concept, instead of requiring a patient to make several appointments with multiple specialists over a number of weeks to months, a cardiac PCMH would provide a “one-stop shop” for the prICULOS patient with the appropriate team members depending on the needs of the individual patient. We hypothesize that discharged prICULOS patients who are managed in “virtual” PCMH (i.e. using exist clinic space at the Asper Building rather than a new free standing structure) will improve access to appropriate health care services and improve satisfaction for patients, their carers, PCP partner and specialists involved in the care of the prICULOS patient.