5/16/2020

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COVID-19: ICU to Home Transition

Presenters:

Kirby P. Mayer, DPT, PhD

Heidi Engel, PT, DPT

Paul Ricard, PT, DPT, CCS

Jason R. Falvey, PT, DPT, PhD

Moderators:Leonard D. Arguelles, PT, DPT, CCSJim Smith, PT, DPT

Kirby P. Mayer, DPT, PhDUniversity of Kentucky

ICU to Home Transitions

Post-Intensive Care Syndrome

@KirbyMayerDPT

Disclosures

No financial disclosures to announce

Acknowledgments

Ashley Montgomery-Yates, MD Director ICU Recovery Clinic

Kirby P. Mayer, DPT, PhD

Critical Illness

Pre-ICU HealthCo-morbidities

PsychosocialSupport

Activity Level/PLOF

ICU Critical illness

SedationVentilationImmobility

Sleep disruptionOrgan failure

Sepsis/infection

Ward/FloorResolving acute illness

FatigueWeakness

Delirium/Cognitive dysfunction

Anxiety/depressionSleep disruption

HomeNew co-morbidities?Resolving symptoms?Prolonged disability?

Dependency?Lost wages?

Readmission risk?Follow-up care?

RehabPhysical deficits

Cognitive dysfunction Anxiety

DepressionSleep disruption

PTSD

Collins TL, Falvey JR. Home Healthc Now. 2019

Kirby P. Mayer, DPT, PhD

Critical Illness

Iwashyna, T. J. Trajectories of recovery and dysfunction after acute illness, with implications for clinical trial design. American journal of respiratory and critical care medicine, 186(4), 302-304; 2012.

Kirby P. Mayer, DPT, PhD

Intro to PICS

Post Intensive Care Syndrome

Cognitive Mental Health

• Weakness• Functional

impairments• Pulmonary deficits• Dysphagia• Pain• Sleep disruption

• Memory loss (short and long-term)

• Attention deficits• Motor planning • Executive function

impairments

• Anxiety• Depression• Mood disorder• Post-traumatic

stress disorder (PTSD)

Physical

Needham 2012 Critical Care MedSmith 2020 PTJ

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Intro to PICS

Needham 2012 Critical Care Med

Kirby P. Mayer, DPT, PhD

Risk factors for PICS

High disease severity

Female

Age

Co-morbidities

Mental Health

Prolong MV

ARDS

Immobility

Delirium

Risk factors

PICS

Lee 2019 Aus Crit Care

Intro to PICS

Inoue 2019 Acute Med & Surg

Covid-19 (viral infections)

Delirium

Anxiety, depression & PTSD

One year after critical illness • 10-20% incidence of PTSD• 30-40% incidence of depression • 32% incidence of anxiety

(Hatch et al. 2018)(Parker 2015)(Nikayin et al. 2016)(Rabiee et al. 2016)

PICS-family• Significant variations in reporting • Prevalence of anxiety 2-80%, depression ranges 4-94% and PTSD 3-62%

(Johnson, Suchyta et al. 2019)

Cognitive Impairments

One year after critical illness • 50% have cognitive impairments (ARDS survivors)

(Hopkins et al. 2005)

• 34% of critical illness survivors had scores similar to moderate TBI on the RBANS and TMT

(Pandharipande et al. 2013)

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Physical Impairments & Disability

One year after critical illness • Up to 70% of survivors will still have a physical complication• 33% report disability with ADLs• 33% unable to return to driving• 44-70% will not return to prior level of employment

• 31% will have a major occupation

Two years after critical illness • 6-minute walk distance: 52-69% predicted • SF-36 PFS mean 72%

Five years after Critical illness• 6-minute walk distance = 76% predicted

(van der Schaaf et al. 2009)(Ohtake et al. 2018)(Kamdar et al. 2017)(Herridge et al. 2011)(Fan et al. 2014)

F u t u r e D i r e c t i o n sTransitions from ICU to Home

ICU Primary team physician, resident, advanced nurse

practitioner, nurse, consulting physician,

resident, physical therapist, occupational therapist,

respiratory therapy, dietician, nursing

technician, mobility ability, nurse manager, hospitalist

REHAB Primary team physician,

advanced nurse practitioner, nurse, physical therapist,

occupational therapist, respiratory therapy,

dietician, nursing technician

HOMEPrimary Care Provider,

Nurse, physical therapist, occupational

therapist

20

10

1-4

Kirby P. Mayer, DPT, PhD

Resources

http://www.icudelirium.org/testimonials.html/

Facebook group for ICU Survivors

https://www.sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome

https://www.aftertheicu.org/what-is-pics

https://www.myicucare.org

https://www.improvelto.com/

Kirby P. Mayer, DPT, PhD

References1. IwashynaTJ. Trajectories of recovery and dysfunction after acute illness, with implications for clinical trial design. American journal of respiratory and critical care

medicine. 2012;186(4):302-304.2. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Critical

care medicine. 2012;40(2):502-509.3. Smith JM, Lee AC, Zeleznik H, et al. Home and Community-Based Physical Therapist Management of Adults With Post–Intensive Care Syndrome. Physical therapy.

2020.4. Lee, M., et al. (2020). "Risk factors for post–intensive care syndrome: A systematic review and meta-analysis." Australian Critical Care 33(3): 287-294.5. Inoue, S., et al. (2019). "Post-intensive care syndrome: its pathophysiology, prevention, and future directions." Acute Med Surg 6(3): 233-246.6. Ohtake PJ, Lee AC, Scott JC, et al. Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's

International Classification of Functioning, Disability and Health Framework. Physical therapy. 2018;98(8):631-6457. Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011 Apr 7;364(14):1293-1304.8. Marra A, Pandharipande PP, Girard TD, et al. Co-Occurrence of Post-Intensive Care Syndrome Problems Among 406 Survivors of Critical Illness. Critical care medicine.

2018;46(9):1393-1401.9. Jackson JC, Pandharipande PP, Girard TD, et al. Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU

study: a longitudinal cohort study. The Lancet Respiratory medicine. 2014;2(5):369-379.10. van der Schaaf, M., et al. (2009). "Poor functional recovery after a critical illness: a longitudinal study." J Rehabil Med 41(13): 1041-1048.11. Kamdar, B. B., et al. (2017). "Return to work and lost earnings after acute respiratory distress syndrome: a 5-year prospective, longitudinal study of long-term

survivors." Thorax.12. Hopkins, R. O., et al. (2005). "Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome." Am J Respir Crit Care Med 171(4):

340-347.13. Hatch, R., et al. (2018). "Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study." Crit Care 22(1): 310.14. Johnson, C. C., et al. (2019). "Psychological Sequelae in Family Caregivers of Critically III Intensive Care Unit Patients. A Systematic Review." Ann Am Thorac Soc 16(7):

894-909.15. Pandharipande, P. P., et al. (2013). "Long-term cognitive impairment after critical illness." N Engl J Med 369(14): 1306-1316.16. Rabiee, A., et al. (2016). "Depressive Symptoms After Critical Illness: A Systematic Review and Meta-Analysis." Crit Care Med 44(9): 1744-1753.17. Nikayin, S., et al. (2016). "Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis." Gen Hosp Psychiatry 43: 23-29.18. Fan, E., et al. (2014). "Physical complications in acute lung injury survivors: a two-year longitudinal prospective study." Crit Care Med 42(4): 849-859.

Over 400 manuscripts in PubMed with search term “post intensive care syndrome”roughly 120 since January 2019

Transitions from ICU to Home for COVID-19 PatientsAPTA Academy of Acute Care PT

Heidi Engel, PT, DPTHeidi.engel@ucsf.edu@HeidiEngel4

The Way We Were

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ICU Early Mobility for Non-COVID

“ When am I going to walk? I walked yesterday. It’s better than just being in the chair. I feel better when I am walking.”-Patient with ARDS acute on chronic pulmonary condition

Early was within a few days of admission to ICU

Family

Communication

Reducing isolation

The COVID-19 ICU Mobility Reality

Need for prolonged sedation, paralytics, prone position

Isolation and noise

Delirium

Hemodynamic lability

Neurologic symptoms

The Underwater Phase (1 to 4 weeks)

• Fast descent into hypoxemic respiratory failure requiring transition from HFLO2 to intubation.

• Requires ARDS Net lung protective ventilation

• Weeks of deep sedation, paralytics, NiO2, pressor medications, prone positioning, CRRT, a-fib, amiodorne, CRRT circuit clotting, DIC, skin rash, multi-organ dysfunciton cytokine storm

Resilience

Admitting

Event

(not the same as

diagnosis)

Week 1

Disease and Chronic Medical Burden, Co-morbid conditions

Week 2

Physiologic Reserve, Functional Baseline, Psychosocial Support, Physical Performance History, Age

Week 3 and beyond

A perturbing altered reality

Disturbed sense of time- time lost, disoriented sleep-wake cycles

Omnipresent feeling of fear, overwhelming powerlessness, learned helplessness, agoraphobia, kinesiophobia, regression- pacifier devices

Disconnected discordant identity

Isolation versus the impact of human connection, a sense of disconnection from inability to communicate

Perceiving surreal eventsOrtega, DG (2019).

Timing- ICU Liberation Still Applies

“In adjusted models, those who implemented exercise with sedation interruption and delirium screening were 3.5 [CI 1.4-8.6] times more likely to achieve higher levels of exercise in ventilated patients than those who implemented exercise without both sedation interruption and delirium screening. “

Miller MA, Govindan S, Watson SR, Hyzy RC, Iwashyna TJ: (2015).

Klompas M, Anderson D, Trick W, Babcock H, Kerlin MP, Li L, Sinkowitz-Cochran R, Ely EW, Jernigan J, Magill S et al: (2015).

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The Roller Coaster emerging from Underwater phase

PT Evaluation initiated when SAT/SBT begun, finding right timing in the patient day can cause more delay

Hemodynamically labile, unpredictable drop or rise in BP or HR, with work of breathing supported during PT, does not tend to de-sat, LOW activity tolerance, frequent rest breaks during activity.

Start learning survival is possible

Upright is normal

This Photo by Unknown Author is licensed under CC BY

Adaptions- ICU Acquired Weakness

Change in architecture of muscle fibers within 18 to 69 hours

Loss of bone mineral density, bone adapts to the load placed on it, ALI patients have 19% greater risk of fracturing, 10 day study with average patient age of 55

Frailty: Fried Frailty Index, hallmark is neuromuscular weakness, every 1 pt increase equal to 3X increased risk of 6 month mortality, 82% of older ICU survivors qualify as frail

Kress JP, Hall JB (2014) Puthucheary ZA et al (2013) Baldwin MR et al: (2014).

Bringing the fragmented self together phase

• Fear anxiety and needing to learn the bed is not home and safety

• Upright is normal adaption

• Activity creates cognitive dissonance

• Integrating lost time, considering the future

• Support work of breathing, dyspnea

• Standing activity prior to extubation, finding midline and COG, repeated isometric holds

• Family support, palliative care to process loss and grief

This Photo by Unknown Author is licensed under CC BY-SA-NC

Not Even COVID-19 Will Weigh Us Down

• Photos and family and Zoom

• Humanity and touch

• Consistent familiar providers

• Music

• Treating pain, providing comfort

• Celebrating milestones

• Preparing for transitions

The marathon training phase begins

Transitions of self-awareness, Borg RPE, HIIT

Muscle recruitment, postural integrity, core strength, balance, endurance, shoulders- rotator cuff and gastric soleus muscles

Peripheral nerve injuries, musculoskeletal pain

PT activity forces reality of situation onto patient

Family education, windows, transition to greater autonomy and self-directed care

20 to 30 sessions of PT later, patients are walking and going home

References

Miller MA, Govindan S, Watson SR, Hyzy RC, Iwashyna TJ: ABCDE, but in That Order? A Cross-Sectional Survey of Michigan ICU Sedation, Delirium and Early Mobility Practices. Annals of the American Thoracic Society 2015.

Klompas M, Anderson D, Trick W, Babcock H, Kerlin MP, Li L, Sinkowitz-Cochran R, Ely EW, Jernigan J, Magill Set al: The Preventability of Ventilator-associated Events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2015, 191(3):292-30

Kress JP, Hall JB: ICU-acquired weakness and recovery from critical illness. N Engl J Med 2014, 370(17):1626-1635.

Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al: The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. J Crit Care 2014, 29(3):401-408.

Puthucheary ZA, Astin R, McPhail MJW, Saeed S, Pasha Y, Bear DE, Constantin D, Velloso C, Manning S, Calvert Let al: Metabolic phenotype of skeletal muscle in early critical illness. Thorax 2018, 73(10):926-935.

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From ICU to Home: Leveraging Rehabilitation

Paul Ricard, PT, DPT, CCS

Rehabilitation Team Coordinator: Cardiac Service

Johns Hopkins Medicine

@HopkinsAMP @RehabHopkins @ICUrehab

Pre-COVID-19: Bedrest is Bad

Hospital-acquired physical impairment is

associated with INCREASED:

• Hospital-acquired complications

• Hospital length of stay

• 30-Day readmissions

• Nursing home and rehab stays

• Long-term impaired physical function

Covinsky et al. J Am Geriatr Soc. 2003; 51: 451-458. Brown et al. J Am Geriatr Soc. 2004; 52: 1263-1270. Brown et al. JAMA. 2013; 310: 1168-1177.Hoyer et al. J. Hosp. Med. 2014; May;9(5):277-82

Disease

DebilityCo-morbidity

Leverage Our Models of Care:

Activity and Mobility Promotion (AMP), Adult

ICURehab, and Pediatric ICU (PICU Up!)

Essential concepts:

• Early and frequent mobilization

• Systematic measurement of function – “Common Language”

• Interdisciplinary team:

– nursing, rehabilitation team, respiratory team and medical team

• Normalize the 24 hour clock

– Sleep, Rest, Active

– ADLs: mobility with purpose

– Orientation to day and night

Critical Care Rehabilitation

Interdisciplinary Activity Mobility Program (AMP)

Rehabilitation

Consultation

Inpatient

Rehabilitation

Facilities

Homecare

Outpatient

Rehabilitation

Pre-COVID-19: Rehabilitation Continuum

Critical Care Rehabilitation

Interdisciplinary Activity and Mobility Program

(AMP)

Rehabilitation

Intervention

Inpatient

Rehabilitation

Facilities

HomecareOutpatient

Rehabilitation

COVID-19: Altered Health System

Critical Care Rehabilitation

Interdisciplinary Activity and Mobility Program

(AMP)

Rehabilitation

InterventionHomecare

Tele-

outpatient

COVID-19: Leveraged Health System

No further

Rehabilitation

Needs

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4 Rights

• Right patient– Functional and cognitive

screening

• Right time– Early, often

• Right intervention– Activity, Mobility, Impairment-

based

• Right provider– Define scope of practice not

roles

“Hospital Direct Home” Framework

1. “Common Language” of function

a. Capacity: AM-PAC Inpatient Mobility and Activity Scales (6 Clicks)

b. Performance: Johns Hopkins – Highest Level of Mobility (JH-HLM)

2. Utilize established ICU rehab criteria

3. Stratify patients

4. Establish formal interdisciplinary activity and mobility plans

5. Communicate variance from plans

COVID-19 Functional

Recovery Model

Low function

AM-PAC ≤ 12

> LOS

Moderate Function

AM-PAC (13-17)

IRF

Higher function

AM-PAC (18-23)

Home/Homecare

Nurse led AMP

AM-PAC=24

Home

Critical Care

- PRONE team

- Respiratory Therapy

-Rehabilitation

Diane U. Jette, et al. AM-PAC "6-Clicks" functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014 Sep; 94(9):

1252–1261.

COVID-19 Functional Recovery Model

RN/RT Led

Swallow: Unable to maintain alertness

Trach: Unable to tolerate cuff deflation

Low Function

Swallow: NPO, pureed solids; thickened liquids

Cognition: Eval for new deficits (not delirium)

Moderate Function

Swallow: Minced -Moist diet or Soft -bite sized diet

Cognitive interventions

Trach: Speaking valve

High Function

Swallow: Regular diet and thin liquids

Cognition: Baseline cognitive deficits

Critical Care

- PRONE team

- Respiratory Therapy

-Rehabilitation

Institutional Scope of Practice

Provider

• OT

• PT

• SLP

• Physiatry

Problem

• Cognition

• ADLs

• Positioning

• Ventilation

• Functional task

• Swallowing

Outcome

• Leaving ICU

• Leaving Hospital

• Needing ongoing care

Rehabilitation TEAM

• Multidisciplinary

• Daily Discussion

• Consistent

application

• Patient focused

Rehabilitation

(PT, OT, SLP, Rehab Psych)

Nursing

Respiratory Therapy

Physicians

(Critical Care,

Physiatry,

Hospitlaists)

PATIENT

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Patient Case

Patient

• 45 year old

• Admitted OSH 3d SOB

• Dx COVID 19 and

transferred JHH on HFNC

• Intubation 2d later,

sedated, prone, paralyzed

Response

• Prone team activated

– Some teams included

therapy

• RT involved

– Some rehab staff assisting

RT with care

• OT consulted for splinting

and positioning

• RN splinting, positioning

Patient Case

Patient

• Failing ventilation and

oxygenation in prone

subsequent

– ECMO

– Supine

– Tracheostomy

Response

• OT evaluation

– Splinting

– ROM

– Education

• OT or RT daily

communication with PT

• RN for splinting and

positioning

Patient Case

Patient

• Sedation intermittently

weaned

• Remained on ECMO

Response

• OT following

– Cognitive assessment and

intervention

– ROM

– Splinting

• OT increased frequency

of sessions

• RN for splinting,

positioning and activity

Patient Case

Patient

• ECMO decannulation

• Mechanical ventilation

weaning

– Trach collar trials

• Low AMPAC score during

therapy and RN scoring

Response

• OT: ADLs, splinting, activity,

communication

• SLP: EMST, communication

• PT: IMST/EMST, ADLs,

mobility

• Coordination of therapy

(Activity and mobility) with

RN

Patient Case

Patient

• AMPAC score during

therapy session >=12/24

• Off mechanical ventilation

Response

• ARISE

– Physiatry consulted

– OT and PT increased

frequency

– SLP progressed to

speaking valve

• Coordination of therapy

with routine RN cares

Patient Case

Patient

• AMPAC score 18/24

• Patient walking with

supervision but SOB

• Persistent cognitive

impairments

• Discharge planning

initiated

Response

• OT following for cognition

with tele-health

• SLP for swallowing

• PT for IMST/EMST and

interval training

• RN providing activity and

mobility opportunities

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Patient Case

Patient

• AMPAC 24/24

• Walking modified

independent using walker

• No longer SOB with home

mobility

• Decannulated, full diet

• Cognition slightly impaired

• Transition home

Response

• D/c’d with individualized

home exercise program

• Activity and mobility with

RN

• Communication with

home therapy

Once Home….

Coming soon to a theater near you:

COVID-19 Multi-Disciplinary Service: Addressing Post-Intensive

Care Syndrome.

The Pulmonary Critical Care Medicine, Physical Medicine &

Rehabilitation and Homecare Collaborative.

Resources

• PACER series: Free webinar through APTA

https://learningcenter.apta.org/student/Catalogue/CatalogueCategory.aspx?id=dcbae4dc-

1a13-42ff-b9da-7ba7a62162e9

• APTA endorsed Australian-based guideline for practice guidelines for PT in the Acute

Care Setting with COVID- patients

http://www.apta.org/uploadedFiles/APTAorg/News_and_Publications/Latest_News/News_

Items/2020/Physiotherapy_Guideline_COVID-19.pdf

• Comprehensive living document with links to up to date guidelines, webinars,

resources for both COVID and general critical care therapy by Kyle Ridgway, PT

https://docs.google.com/document/d/16UrBoE0YLikWaXgdUpmO01oO2NTo5fr-

_qkN3EyDvr0/mobilebasic

@ICUrehab

Learn more: hopkinsmedicine.org/pmr/amp

Newsletter and Training: HopkinsAMP@jhmi.edu

The Show Must Go ON! Live or Virtual@Hopkins AMP, @icurehab, @PICU_Up

5/16/2020

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Care Transitions After COVID-19 Infection

Jason R. Falvey, PT, DPT, PhD

Board Certified Geriatric Clinical Specialist

Post-Doctoral Fellow

Yale University School of Medicine

From Hospital to Home After COVID-19 Infection

How can we set patients up for successful transitions into the community?

Maximizing in hospital physical function

Reducing unmet needs for ADL assistance

Facilitating rehabilitation continuity over the next 30 days

@JRayFalvey

Impaired Physical Function as a Biomarker

Measures of physical function (ADLs) and capacity (i.e. walking ability) consistently have been associated with readmission risk

Importantly, physical function may be a modifiable risk factor for readmissions

Trajectories of functional change AFTER hospitalization also prognostic

@JRayFalvey

Impaired Post-Hospitalization Function and Readmission

@JRayFalvey

Discharge Physical Function and Readmission Risk

Journal of Hospital MedicineVolume 9, Issue 5, pages 277-282, 26 FEB 2014 DOI: 10.1002/jhm.2152http://onlinelibrary.wiley.com/doi/10.1002/jhm.2152/full#jhm2152-fig-0002

@JRayFalvey

Function and Readmission After Serious Illness

TUG >25 seconds at hospital discharge increases odds for readmission 86% AFTER myocardial infarction

Dobson et al, 2019

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Unmet Needs for ADL Assistance

Ensuring patient needs for ADL assistance are met during transitions home is critical

Unmet ADL needs are associated with a 37% increase in readmission risk (DePalma et al, 2013)

Trajectories of Recovery And Readmissions

Once older adults go home from hospitals or post-acute care settings, what happens in the early post-hospitalization period is critical

@JRayFalvey

Trajectories of Recovery And Readmissions

In –Hospital SPPB Score and 30 Day Change

Rate of decline after hospitalization

Re-hospitalization Rate Mortality

Medicare Priority Diagnoses (i.e. pneumonia and heart failure)

Volpato, 2011@JRayFalvey

Trajectories of Recovery And Readmissions

Any decline in physical function within 30 days AFTER hospital discharge is associated with a 250% increase in risk for hospital readmission or death

@JRayFalvey Volpato, 2011

Steve R. Fisher et al. J Gerontol A Biol Sci Med Sci

2012;gerona.gls252

Steps per day in older adults

NOT readmitted to hospital

Trajectories of Recovery And Readmissions

@JRayFalveySteve R. Fisher et al. J Gerontol A Biol Sci Med Sci

2012;gerona.gls252

Steps per day in older

adults readmitted to

hospital

Steps per day in older adults

NOT readmitted to hospital

Trajectories of Recovery And Readmissions

@JRayFalvey

5/16/2020

12

Role of Home Health in Successful Transitions

Using Medicare home health care improves transitions to the community after acute medical illnesses

9% reduction in readmission rates when going to home care, despite higher medical complexity (Weerahandi et al, 2019)

Yet only 20% get referrals!

More days at home despite higher medical complexity (Simning et al, 2020)

Rehab Use and Readmissions

For patients receiving care at home following hospitalization, higher doses of physical therapy are associated with up to 82% lower odds for readmission (Wang et al, 2019)

• Doses of 1 visits per week minimum

Evidence that rehab meaningfully impacts readmission risk

@JRayFalvey

Summary

@JRayFalvey

References:

• Dodson, J. A., Hajduk, A. M., Murphy, T. E., Geda, M., Krumholz, H. M., Tsang, S., ... & Alexander, K. P. (2019). Thirty-day readmission risk model for older adults hospitalized with acute myocardial infarction: the SILVER-AMI study. Circulation: Cardiovascular Quality and Outcomes, 12(5), e005320.

• DePalma, G., Xu, H., Covinsky, K. E., Craig, B. A., Stallard, E., Thomas III, J., & Sands, L. P. (2013). Hospital readmission among older adults who return home with unmet need for ADL disability. The Gerontologist, 53(3), 454-461.

• Volpato, S., Cavalieri, M., Sioulis, F., Guerra, G., Maraldi, C., Zuliani, G., ... & Guralnik, J. M. (2011). Predictive value of the Short Physical Performance Battery following hospitalization in older patients. Journals of gerontology series a: biomedical sciences and medical sciences, 66(1), 89-96.

• Fisher, S. R., Kuo, Y. F., Sharma, G., Raji, M. A., Kumar, A., Goodwin, J. S., ... & Ottenbacher, K. J. (2013). Mobility after hospital discharge as a marker for 30-day readmission. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 68(7), 805-810.

• Hoyer, E. H., Needham, D. M., Miller, J., Deutschendorf, A., Friedman, M., & Brotman, D. J. (2013). Functional status impairment is associated with unplanned readmissions. Archives of physical medicine and rehabilitation, 94(10), 1951-1958.

• Weerahandi, H., Bao, H., Herrin, J., Dharmarajan, K., Ross, J. S., Jones, S., & Horwitz, L. I. (2020). Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization. Journal of the American Geriatrics Society, 68(1), 96-102.

• Simning, A., Orth, J., Wang, J., Caprio, T. V., Li, Y., & Temkin‐Greener, H. (2020). Skilled Nursing Facility Patients Discharged to Home Health Agency Services Spend More Days at Home. Journal of the American Geriatrics Society.

• Wang, J., Liebel, D. V., Yu, F., Caprio, T. V., & Shang, J. (2019). Inverse dose-response relationship between home health care services and rehospitalization in older adults. Journal of the American Medical Directors Association, 20(6), 736-742.

COVID-19: ICU to Home Transition

Leonard D. Arguelles, PT, DPT, CCS

Kirby P. Mayer, DPT, PhD

Heidi Engel, PT, DPT

Paul Ricard, PT, DPT, CCS

Jason R. Falvey, PT, DPT, PhD