ICU survivors are complex patients and, after hospital discharge, may become “lost” in the healthcare system with delays in accessing clinical care that recognizes and proactively addresses their unique limitations and needs. Indeed, a recent cohort study suggests that while recommended practices for post-sepsis care (medication optimization, screening for new impairments, monitoring for common and preventable causes of health deterioration) are associated with improved outcomes, only a minority of patients receive all items [
42]. Based on these arguments, a dedicated, multidisciplinary post-ICU follow-up service or clinic to assess and manage PICS problems may be justified. Such services are increasingly available and have been shown to have promising results on mental outcomes [
43], although published data in this field are still limited and sometimes controversial, with two randomized controlled trials showing no benefit on selected outcomes of the mode of follow-up tested [
44,
45]. The practical modalities of post-ICU clinics are loosely defined and vary widely in terms of involved professionals, patient eligibility, timing and duration of follow-up, and criteria for specialist referral. There are no clear criteria to guide which survivors should be included in follow-up programs. Patients with anticipated better outcomes because of a lower severity of illness or a shorter length of stay should not be overlooked. Intensivists, particularly those with a special interest in this area, may be best qualified to understand all the aspects of critical illness a patient may have encountered and likely post-ICU sequelae, and should probably be key players in the design and running of such services along with nurses and allied health professionals (e.g., pharmacists, physiotherapists, occupational therapists, psychologists). Many primary care physicians or referring specialists are unaware that persistent sequelae may relate to critical illness, and have little time to correctly manage the multiple, often complex, aspects of PICS. Close collaboration between intensivists and other doctors or services involved in home care and social welfare [
46] is therefore essential. Indeed, there is a general consensus that the transition from in-hospital to outpatient care could be significantly improved [
47], especially in terms of information sharing [
48].
Telemedicine is another option for survivor follow-up. Text messaging or smart-phone applications have become widely used interfaces between patients and their providers. High levels of patient satisfaction, time- and cost-saving, and improved access to care are among the numerous benefits of telemedicine. Mindfulness and coping skills training programs delivered by mobile applications have shown encouraging results in reducing psychological distress in survivors and their families [
49]. In-home telerehabilitation programs, using telephone and video-based interventions aimed at remediating cognitive, physical and functional deficits, may also be feasible. Telemedicine is also increasingly used for peer support chat within support groups of ICU survivors.
In addition to the diagnosis and management of PICS, post-ICU care should aim to prevent readmissions [
50]. Survivors who are particularly frail should be identified early. Medications should be reassessed frequently as vital parameters can be labile in the weeks following hospital discharge, necessitating changes in drug and/or dose. Intervention of an in-hospital clinical pharmacist can help reduce short- and long-term readmissions, especially in patients receiving multiple medications. Vulnerable patients should be educated on risk of re-infection and the swallowing function should be assessed. Physicians should ensure vaccines are up to date, and splenectomized patients are aware of their increased susceptibility to sepsis.