D25-22 Post-intensive Care—Transitional Care, Rehabilitation, and Family Support (pic-trfs): A Theory-driven Model of Community Reintegration After Critical Illness

Rationale Theories of change (De Silva, 2014) explain how and why desired outcomes are expected to occur within a particular context, while intervention models operationalize those theories into concrete processes for achieving change. We sought to develop a theory of change to promote return to mainstream community and family life roles (“community reintegration”) in the context of functional impairments acquired during critical illness. We then applied the theory to develop an intervention model. Methods Using participatory methods, we engaged patients, families, clinicians, and researchers to co-develop a theory of change describing processes (“how”) that facilitate and mechanisms (“why”) by which successful community reintegration occurs. Following Medical Research Council guidelines, we translated the theoretical hypotheses into a testable intervention model, which we further refined in a feasibility pilot study with n = 21 patient-family dyads. Results The PIC-TRFS Theory of Change specified 4 main hypotheses: (1) Social care helps patients and families learn and practice new health behaviors, thereby increasing self-efficacy and community reintegration; (2) Rehabilitation facilitates the development of transferrable skills for engaging in self-selected activities, thereby increasing self-efficacy and community reintegration; (3) Access to community resources improves community reintegration; (4) The strength of relationship between the patient-family caregiver dyad and the social care and rehabilitation interventionist enhances community reintegration. To operationalize these hypotheses, the PIC-TRFS intervention model integrated 3 evidence-based approaches: (1) the Patient Priorities Care model to align care with patient-defined goals and support goal-directed behavior change; (2) Strategy Training to practice and build transferrable skills in adaptive functioning for self-selected activities; and (3) the Transitional Care Model to assess needs and coordinate health care, social support, and community resources. The feasibility pilot study findings led us to refine the intervention model by: (1) shifting emphasis from medical to social prescribing (e.g., community exercise programs or volunteer activities; (2) adapting patient-facing materials (i.e., study workbook) to actively support behavior change; (3) adopting a lighter-touch, longer-duration format; and (4) simplifying process and outcomes measures. Conclusions PIC-TRFS is a theory-driven, multi-component intervention that complements usual care by promoting positive coping and community reintegration after critical illness. Its efficacy compared with enhanced usual care is currently being evaluated in an ongoing randomized control trial (NCT 06501365). This abstract is funded by: AHRQ K08HS027210