All right, so welcome to our discussion session. So again, I want to really thank Miss Annie Johnson and Dr. Michelle Beale being here to do this. Obviously, in the actual session, we're hoping this to be more interactive, but we have some kind of questions that I was going to ask our panelists. And unfortunately, due to some extenuating circumstances, Dr. Efron wasn't able to join us for this conversation, but I'm sure if you email him or any of us, if you have any further questions for the audience, please feel free to do so. So you've already met our expert panelists regarding this topic. And so I thought I'd take a moment and just post some questions. And maybe what I'll do is again, I'll ask one of you and then the other, if you have a comment or suggestions, I encourage you to just chime in if that's okay. Perfect. So I thought the first question I think is, what's the key hurdle? So Annie, this is for you. What's the key hurdle in getting the PICS clinic started? And how did you, what were some hurdles and how did you overcome them? If you can talk about that. Yeah, so yeah, I think that's one of the most common questions asked by, especially by organizations that are just exploring the, you know, in the beginning phases of, of starting a recovery clinic. And I think one of the most common responses that you'll hear from conversations through reading papers that have been put out about this is funding. So that tends to be the biggest barrier. Of course, there's other barriers along the way, but for example, just to kind of talk about our timeline at Mayo Clinic with our, with our recovery clinic, we really started the conversation in 2015. So the interest really started going, we got a team together, we started doing some preliminary research and our clinic didn't start until late 2019. So it was about, you know, four years after we first started talking about it. And one of the things that really lifted us off the ground, I should say the key thing that got us off the ground for our clinic is getting funded by an award. So that helped, that kind of erased that piece of it. And as soon as that, as soon as we got that award, it was like, go, go, go. And we, and we built the clinic and we went kind of at warp speed with that. So that really proved to me that that was the key. That was a key thing. The last piece of the puzzle that we really needed to launch our clinic. So, yeah, so I'd say that's the key. There's, there's several others, but that would be the biggest, the biggest barrier to really getting that push forward. Yeah. I have a related question, but Dr. Beal, your, your, your perspective, anything to add to that? Yeah. Yes. Thank you, Annie. I think, you know, we share a lot of things in common. We also spend a good time brainstorming how to start the clinic and getting the team together. So it was about a little, I would say over a year. But for us, we did not get funded. I think the, the, the, the main thing was to get the buy-in from leadership to explain why you wanted to do that. And to show that might not initially be, you know, you know, generating, you know, benefits RVU wise, but it would be like cost effective in terms of patient benefits, less ICU, less hospitalizations and benefiting patients, support patients and families and recognizing all of the, you know, the impairments of the ICU survivors that have not been met and showing that there is a big need. And, and also I think showing, you know, to the leadership and colleagues, educating them on the ICU survivorship and showing what other hospitals, other big centers are doing. So I think we did get, you know, aligned with leadership. We, our leadership, our department, we wanted to have a continuum of care for the ICU survivor from the, from the ICU stay to the hospital floor. We have like a transitions team who are following these patients already on the hospital nursing floor. And then the next step would be to follow them up in a clinic. So I think, you know, that was the main thing. Once we got that, you know, from the group of people who would support us we were able to keep moving forward with, you know, all of the logistics, which is, it's a lot of things to get that in place, but yeah. Yeah, no, I think that's funding and getting the leadership buy-in obviously is a huge thing, I guess. So related to that, can I ask what funding you applied for and what funding opportunities that might be? Was it in the intra-clinic or was it from an external funding source? Yeah, so it was internal funding that we got through a practice award through Mayo. Yep, yep. So we received that. And interestingly, we got that in kind of the middle year of 2019. And then, of course, we all know what happened at the beginning of 2020, where everything stopped. But we actually out of, out of the teams who received CPC award funding, and had projects going under that, everything kind of stopped because of the pandemic and everything kind of froze. And we didn't know where we'd be financially, many organizations did that. So all I believe other projects were stopped, but they selected ours actually to keep going. So ours was, I think the only project at the time that was approved to keep going. Because at that point, kind of a funny thing that COVID did was really bring awareness to all of this and the importance. So we stress like now more than ever, this is what our patients are going to be needing. And there's going to be more, you know, post ICU patients that we've seen before. And so they started recognizing like, oh, this is what you guys have been talking about, you know, and we got to keep this going, we got to keep it funded. So that was that was key to is that the, you know, generosity and recognition by the clinic that it was the importance of it and to keep it funded and keep it going. Yeah, no, that's, that's excellent. I guess. So in that, so we'll get to that and talk in terms of how to sustain this during COVID. But I guess the next question and kind of building and as people are thinking about creating their own or starting their own recovery clinic, what were some tricks Dr. Beal, I'll look to you, what were some things that you felt was important in getting that leadership buy in to say, yes, we agree with you that this is important, obviously, and you've talked about part of this pandemic and recognizing the importance of it, but as you're as you're developing it, what what did you feel was important to get that leadership buy in? Sure, so I and we developed our clinic just before COVID hit. So it was December 2019, when we started when you open. So I think it's educating them and showing the why that we want to do this showing the need and the importance. So there was a lot of that education on survivorship, which fortunately has increased significantly with COVID, I think is the silver lining. But before that, a lot of our colleagues, you know, even critical care physicians were not aware much of what all the impairments patients have. And if you don't recognize they're going to go, you know, no one is going to evaluate and treat them accordingly. And these patients, you know, they have a significant burden in their journey to recovery. So, you know, showing that and I think getting a group of clinicians that are passionate about that. So it's not just me. So we had a group of clinicians that were like passionate about in terms of like being dedicated, devoted, we want to do this and why being resilient, persistent, because it's not easy, you have to be really be, you know, going over and over, you know, why we want to do this. And, again, there is not a lot of data yet, you know, showing that this is, you know, reduce morbidity, mortality, or ICU, you know, or ICU readmissions, or hospital readmissions. So it's still like coming out of that, that the data to studies, but showing that the importance for these patients and how this can go unrecognized. And I think all of us know how often these patients get readmitted, right? So they leave the ICU a month later, they come back. And what can be done in that meanwhile to prevent that? So I think, you know, getting the buy in showing the why, and, and getting a group of clinicians that were, you know, passionate about and keep persisting on our goals, by finding our team. Yeah, absolutely. Any, anything to add to that, from your perspective? Yeah, um, I totally agree that that buy in is often identified as the the key factor in showing that why telling telling that patient story. So that's a really key way that we've that we've been able to do that. And other organizations have talked about having success with getting buy in is really connecting that patient story back. So some people So some people have invited like the admins into the clinic for a day to see how things run and really understand what it is that you do during clinic and the importance of it. It's really hard to walk away from clinic after hearing directly from these patients and be like, man, we don't need that. It's a really hard thing to do. So I know other clinics have been successful at, you know, kind of pulling that piece in, you know, and really, really getting that, you know, kind of solidifying that buy in from their from their admins. And another big question that often gets asked from organizations is, you know, well, don't they follow up with their primary care provider? Why do we need another clinic for this? So answering those questions, and really making it clear, like what sets these clinics apart from follow up processes that are already in place for patients. So, again, having them see it firsthand during during a clinic can really make it clear what's different, that, you know, we're looking at things from such different perspectives. And why is it that we need to connect the critical care specialists back with these patients? Yeah, no, I think those those are all very important. And I guess as a as a build into that, in terms of buy in, obviously, the success of a clinic like recovery clinics, is that you have, it's a multidisciplinary clinic, in a sense that that's what I think one of the big thing that sets it apart from just following up their primary is that you have your other individuals, whether it's a psychologist, occupational therapists, you know, all these other people. So I'd imagine it took both of you some work to pull in that team from different divisions. And was it I'm assuming it would be similar in terms of educating and getting some champions from those areas. Any tips for those who are out there in terms of trying to start that process? Because obviously, you need to build a team before you go to the administrators. Any tips that you might have to getting that accomplished? Dr. Beal, I'll look to you. Oh, yeah. So I think from my standpoint, we looked at what other post-ICU clinics have done. So I visited, I visited Mayo Clinic. So I was fortunate to meet with Annie, at that time, Dr. Mike Wilson, and see their clinic going and have, you know, I think that was crucial for the build of our clinic. We also had Dr. Carla Steven from Vanderbilt coming to do a presentation for us. And also, there was a lot of brainstorming with her. So I think reaching out to other clinics that are already out there, and hearing from them, you know, who do you think should be in the clinic? What which team members are crucial or vital? And if they cannot come, what other ways that you can get the patients to them? And logistics, who should you know, who is the population that you want to recruit to these clinics? Because it's still not, you know, that, you know, the patients who have high risk factors for peaks, but still, it's hard to like, we are going to recruit and in which way to recruit these patients. So, so that was, that was, I think, was very, was vital to getting in touch with other clinics, and utilize, you know, the resource that you have available at your place. So we did, you know, we had an ICU pharmacist that was very involved with Society of Critical Care Medicine, Heather Torbik. So she was, you know, very eager and happy to be part of the clinic. And she then invited other pharmacists to rotate through the clinic, we discussed with physical therapy and occupational therapy, and they were like, also very eager to be part of the clinic, we had to choose one of those, because it's not building, you know, we start adding time, and then cannot have the patient there, like, for six hours, seeing everyone. So we had to choose physical therapy, although the physical therapies does do an evaluation if the patient is OT. We do have respiratory therapies in our floor, the pulmonary, so that was kind of easy. The mental health piece, we wanted to have, you know, someone with mental health background, we did have psychiatry initially part of the clinic, and then eventually we transitioned to asynchronous. So that means that if the patient needs, based on the screenings for anxiety, depression, PTSD, we have a special like care pathway to direct to them with an easier access. And so we built all of those things, the same for neurology, a lot of patients with cognitive impairment, we looked at know what were the physicians or the clinicians who were wanting to see these patients, and we had several meetings, discuss the needs and then have like specialty care pathways to direct these patients there. So they're not like waiting months to be seen by these specialties. Again, several, you know, you know, months, or, you know, over a year planning all of these until you get to start. And, you know, one of the things that I always remember, and I say to others, the next the way to be like everything and the place to start the clinic at some point, just go ahead and start with what you have, because you're going to, you're going to learn so much doing it. And then you're going to tweak and get better and better. We are still like learning and changing a few processes here and there, you know, that's, that's changing this order of providers, that's who is here, so we're still changing and improving. So get your team, but don't don't wait too long, because the patient's benefit, you're going to see right away and you're going to improve as you go. Excellent point that in content, just good and getting at least once you have some of the pieces ready to go get it started and going. Any anything to add to that? Any thoughts? Yeah, no, that I really appreciate that point, Dr. Beal about just, just at some point, just start, you know, don't wait till you feel like you're fully ready, because also what you start with is not going to be what it looks like, you know, months down the road, it's going to look different, it's going to grow, it's going to change. So just start somewhere and start the learning process. And then you're really going to know how to individualize your clinic. And and also remember that your clinics not going to look like everybody else's clinic, whether it be for resource needs, or your specific patient population needs, it doesn't have to, but it is really helpful to connect with the other clinics. And we did the same. So we visited our friends at UPMC. And we also went to Carla's team at Vanderbilt as well. And so connect and network in and really get to know others throughout this process. And that's really going to help you see what what might work really well for your team, what maybe isn't going to be a good fit, but pulling those pieces together. And I'm a huge champion for really trying to stay true to that multidisciplinary piece of it, you might find yourself hearing, you know, from your organization of like, Oh, it can just be the provider, you know, really trying to narrow it down and let's stick to the models that we're comfortable with and we're used to and that we want to stay with because what you're proposing sounds weird and different. And we've never done anything like that before. But really kind of trying to stay true to that multidisciplinary because that to me is what makes these follow up clinics so special and unique and ultimately so beneficial for the patients. As we're talking, I guess a question came up, and I think you briefly mentioned this too, but patient selection, how do you how do you decide what's I mean, in terms of because obviously, we have lots of patients going into the ICU. And so I guess, in terms of trying to understand that, how do you pick the patients, and then maybe correlated to that in terms of how do you respond to the primary provider that feel like you're taking away the patient patients or some of that conflict that they might experience? Maybe any I look, I look to you first to kind of start commenting on that. But so help us at least understand that process and maybe getting the different perspective from both of you to because obviously, at the end of the day, you're going to need the patients and there are many of them, but how do you pull them in? And how do you integrate that with the primary provider? Yeah, so that we we often call that patient recruitment. I don't even know if that's the best term. But that's what we're all used to saying. That is, I think, notoriously the most challenge, one of the most challenging besides giving funding is one of the most challenging pieces to starting a post ICU clinic. And it's the next question after funding that people ask, Well, how do you get patients in and who do you choose? And so, for us, we spent a lot of time researching and looking what other you know, looking at what other programs did, what seemed to be successful for people. And so we just put together our own criteria of which patients we're going to pull in. And you know, when we I look back at our first criteria, and there was probably like a 10 point list, and then, you know, the inclusion criteria, and then as big of one for exclusion criteria. And honestly, right now, for us, it comes down to in ours as an adult clinic. So it's it comes down to being adults being in the ICU for three days or longer, or having been on ECMO. So we have pretty it, we cast a really broad net. So we get a lot of patients that screen in through our EMR, we use epic, we've created registries. So our patients actually automatically filter after they meet those criteria onto a registry. And then our key is having our team social worker, she goes through then everybody who is who needs those criteria, and she connects with them one on one. And she talks to them, she explains the program, she explains the follow up, and what's, you know, the potential benefit that they might have from it, and then they say yes or no to it. And then she gets us gets them into clinic, we have found when we take patients right off of the registry, and just schedule an appointment for them, they don't show up. So it's that connection, we have really found, we kind of did a trial with that. And we have really found that that connection, that conversation with our team social worker has been the key piece to that is for getting them to, to not only say yes, but then to actually show up to the appointment. So so that's, that's been, that's been huge. And since Sarah, our team social workers started doing that for us, we have full clinic 100% of the time people we just have, we have no problem filling up clinic. And then as far as remind me the second part of the question, the kind of the collaboration or mitigating angers from the primary providers? Yeah, yeah. So that's a really good question. I think that's something that we a lot of us have been afraid of, but not something that has really come to fruition, not something that that we've experienced. I haven't experienced any negative feedback from primary care provider, we've seen at this point, over 500 patients. So there's been plenty of opportunity for somebody to have gotten irritated with us. And I haven't heard anything back personally, or from, you know, from any other way either. What has been really fun and rewarding is that connection with the primary care provider. So there's been plenty of times when I've picked up the phone, and I've called somebody because I'm pretty concerned about their patient. And it might be somebody in Iowa or somebody, you know, in a different state, and had a conversation with a primary care provider, saying, we had this opportunity to see your patient. And, you know, I'm just kind of concerned about, you know, blank. And they've always been very thankful. I've never gotten that. Well, who are you? And what are you doing? It's, it's always been a really nice collaboration. And in fact, we've actually had people do the opposite and reach out and refer their patients to us. So I had a I had a primary care provider who actually called me one day, and she said, I have so and so sitting right next to me here in my clinic. And then, and she's requesting to be followed up by your team, how do I put through the order? So it's, it's been a really cool evolution of that. And, yeah, and to really, you know, understand, in no way are we serving as a replacement at all for it, but more of just like this bridge from that scary world that they occupied for a little bit back into their normal life. I would think that in fact, most primary providers would be would welcome the opportunity to unload and help have some help managing these patients. Yeah, yeah. But I think that concern certainly is something that I think we I think it's been kind of discussed and concerned about. Dr. Biel, your perspective on those things, your thoughts, anything to add? Yeah, so I will start today with the collaboration with primary cares. And I absolutely agree with what Annie said, we haven't had any issues at all, we have good, good communication with them, as you know, and have also connected directly with some of their providers, sometimes pulmonologists, sometimes the primary care, we always send a letter that we have seen them and, you know, what we have done, and what, you know, follow ups we are we are doing. And we did have we have been having more, you know, of the primary cares, knowing that we are seeing this patient to, you know, reach out and say, can you see this patient, I think it's having a lot of other issues. And so that has been really, you know, really great. In terms of recruitment, I share, you know, the struggles, I think, with all of the other clinics, we also call recruitment of patients, because I think we need to recruit them that is still not a lot of education has been done to the community, like they they know what is a post ICU clinic, so they're not going to call and ask for, you know, can I go to a post ICU clinic. And I think that the COVID, the silver lining is that it's all of these impairments are now, you know, much more people are much more aware, but we do have a recruitment and we did choose our criteria. We also looked at what others were doing. So our criteria is based on risk factors. So we have patients with ARDS, you know, based on on ICD 10. With prolonged mechanical ventilation, we say over three days, prolonged ICU stay over seven days, any type of shock with use of compressors, also utilizing, you know, EPIC for that. And delirium, you know, any patient can positive over two consecutive measurements by the nurse. So with that, we developed after a long time doing a lot of manpower manually searching these patients, we now have a dashboard in EPIC that kind of, you know, create a registry, like, you know, we call like enrollment, not enrollment, patient, what eligible, so eligibility, and then we have, we don't connect to them in the hospital, we used to do that when you had nurse practitioners and physician assistants working with us, when as soon as COVID hit, they needed to go, there was a different need for them. So we lost, we lost them, we're not working, they're not working with us any longer. So we lost that communication to patients right in the hospital, because we don't have the manpower. But we do have a project manager who calls these patients, because we don't so we have that call saying explaining your ICU survivor, there is this clinic, I'm calling to explain what the clinic is about and, and explain on pixies. And if they accept, then we have we ordered tests needed, and the schedulers will call them and schedule the appointment, either virtual visit or in person. So we do have that and we're still refining the recruitment process. We are looking back at now that we have the dashboard looking back and seeing, you know, what are the patients who most accept what we're declining because they say they're doing well. Some of them may decline initially the call, but then they call later with symptoms, most of those are COVID. So we did add the COVID into our list. So the COVID and 48 hours in the ICU are also part of our inclusion criteria. So so yes, I think that's one of the most difficult things is to get you know, the patients in and access to the, you know, coming to the clinic presenting to the clinic. And I agree with any that if you just schedule them, there's a high no show rate. So you need to have that, that contact and explain what the clinic is, and have them understand, you know, that, you know, what are the benefits of coming their needs, and, you know, you know, they were going to help them through their journey. And we have had low, no show rated. I think it's really interesting how both of you have used different individual social worker, clinic coordinator, and we just did, but it sounds like that it's that more that personal touch reaching out and, and helping them recognize that some of the things that they're experiencing is actually expected, and it's common, and let's talk about it. How can we help you through that? I think that's a that's a really important thing. And about five minutes left or so, I guess the last thing in terms of kind of sustainability in this COVID world, I think it's I'd be remiss to not talk about that. And, you know, maybe it's been easier, maybe it's been harder, both from kind of operationalizing it and also maybe even patient perspective, your thoughts and kind of how they've been received. Maybe Dr. Beal, I'll look to you first and then have Annie kind of wrap up. Sure. So our clinic started just before COVID hit, like, pretty much two months, three months before. So when when the COVID hit, of course, patients didn't want to come in anymore, right? No, it was like, actually, we we stopped seeing patients in the pulmonary clinic for, you know, for some time, everything went virtual. So very quickly, we had to transition to virtual visits, which was something we're planning to implement in our clinic, but probably would take over a year to start that process. And it was like in two weeks, we have everything ready. And then we were getting those patients virtually. And it's I think we when we did that at Cleveland Clinic, the only person in there in the virtual appointment was it was the physician. So we missed that multidisciplinary approach in the sense of having the pharmacist and physical therapy and etc. But we still created this this care pathways that we could send these patients easily to other providers that we know they will often need. And and I think as every other places created very fast, we have seen these patients virtually, you know, with different types of platforms. And patients really adapted also, you know, for the ones who had the resources, they adapted easily to do those virtual visits, and then they will go get tests, and then get another virtual to review the tests. And eventually those patients then when you know, started coming in, those who are still having issues, we did pretty much three months of virtual, and then we started getting back to in person with all of the protocols for infection control that were needed and kept changing over the time. And because we saw we have been seeing a lot of post COVID patients. So we do have a different post COVID clinic in Cleveland clinic, but still the post COVID with ICU stay is, you know, is triage to our clinics. So. So again, we were able I think I think the call the COVID pandemic was the silver lining for all the post ICU clinics in terms of, you know, showing the benefit and, and that was, I don't, I don't think we had issues with sustainability in terms of continue to have the support we needed, transitioning fast to virtual and then back to in person. And now we have open both options for patients, you know, we prefer they come in person, because then that's the beauty of the multidisciplinary team. Some of them prefer initiative virtual, we show them, you know, that they are not alone, all of these issues they're having the others have and how we can help and then they come for in person. So yeah, so I think being able to adapt, you know, with what when things come and utilize the resources you have, is it's crucial for this type of thing. Yeah. Any final thoughts on that? Yeah, so we have essentially the same exact storyline as Dr. Beale and her team with a quick transition to virtual. Because we, you know, we just didn't want to stop and we had always wanted to do the virtual and then we just suddenly did and we though have actually not gone back. So we, we switched to virtual and then we have now stayed 100% virtual. And, and one, one of the papers that was out fairly recently that the SCCM thrive collaboratives put out talked about barriers to implementing these types of programs and clinics. And one of them is patient and family accessibility to clinics. And so what you do find is this patient population is oftentimes still so sick, or, you know, they they have accessibility issues as far as how far they're able to walk and move around. And so we've actually had patients really thank us for, Oh, thank you that I can, you know, sit on my couch here and have a conversation with you. We did have to rearrange, you know, what we did when we were seeing patients in person, we were doing, you know, hand squeeze testing, we were doing, you know, a sit to stand and six minute walks and things like that. And so we did have to become more creative as far as how to still assess patients as, you know, as much as we could virtually, but we've hung on to that multidisciplinary. So we do still, we kept the same myself, our team pharmacist, teams, occupational therapist, fully immersed, and actually got better. Because when we saw patients in clinic face to face, we each saw these patients individually. And now we're all together on every appointment. So we hear 100% of what's going on throughout the whole appointment. And we just bounce ideas off each other. And it's been so fun to learn from each other to from all perspectives. I know more about, you know, occupational therapy than I ever did before this. All sorts of, you know, pharmacy, you know, tips and tricks that I'll chime out now in the ICU, somebody will say something like, actually, Shannon will tell us in the clinic, we should do this. And so it that whole process is just it's been fun to watch how it's grown and evolved and, and it's increased accessibility for the patients and families. And so actually, we've seen a really rapid increase in the numbers of patients that we've been able to see too. So I think it's just holding on to that flexibility and creativity with these clinics and just adapting as we need to. And, and like I said earlier, you know, your clinics not going to look like everybody else's. And that's totally fine. You know, stay true to your, your, you know, goals for your clinic and, and, you know, your mission for your patients. Yeah, no, that's fantastic. And I think throughout the session, obviously, we've talked about the importance of this, and then now kind of operationalizing it. So again, I really appreciate the times that both of you have taken to discuss this important things and some great advices that you've provided. And again, hopefully, you won't mind if people reach out to you if they have any questions or concerns, and have some further discussions. But again, I really want to thank both of you for your time and your expertise. And I hope you guys have a good rest of the day. Thank you.

post-ICU recovery clinic

funding

leadership buy-in

multidisciplinary team

patient recruitment

virtual visits

adaptability