Respiratory Therapist–Led Longitudinal Care from ICU to Rehabilitation and Home for Patients with Tracheostomy and Chronic Critical Illness A Preliminary Practice Report

Background:Patients with chronic critical illness (CCI), particularly those requiring tracheostomy and prolonged respiratory support, often experience fragmented care during the transition from intensive care to rehabilitation and subsequently to the home setting. Caregiver preparedness, airway safety, and timely access to professional support remain major challenges after hospital discharge.Practice Description:We developed and implemented a respiratory therapist (RT)–led three-stage longitudinal care model integrating the intensive care unit (ICU), rehabilitation ward, and home. The model extends RT involvement beyond conventional ICU-based respiratory management to include transitional care and longitudinal home support. In the ICU, RTs participate in protocol-based mechanical ventilation management, airway clearance, bedside bronchoscopy, weaning assessment, and tracheostomy management, while initiating structured caregiver education. During rehabilitation, RTs provide scheduled bedside follow-up, reassess airway status, support respiratory rehabilitation, and reinforce caregiver competency. After discharge, RTs maintain longitudinal contact with patients and families through structured communication, caregiver education, emergency preparedness, home visits when appropriate, coordination of community resources, rapid hospital referral, and interdisciplinary referral.Preliminary Experience:The model has been implemented in our department for 5 years and has included 126 patients with tracheostomy and CCI. During this period, the RT team performed 336 rehabilitation-ward follow-up encounters, and 379 home or remote follow-up encounters. Descriptive observations suggested that the model was feasible and was associated with favorable signals regarding airway safety, caregiver confidence, continuity of communication, and access to medical support. However, these observations were not derived from a controlled comparative study and should not be interpreted as evidence of causal effectiveness.Conclusions:An RT-led longitudinal care model integrating ICU, rehabilitation, and home-based support may provide a feasible framework for addressing fragmented care among patients with tracheostomy and CCI. Its potentially distinctive features include continuity of RT involvement across care settings, structured caregiver competency training, emergency preparedness, rapid escalation pathways, and interdisciplinary coordination:Prospective multicenter studies are warranted to evaluate its effects on clinical outcomes, caregiver burden, healthcare utilization, and patient-reported outcomes.