Post-Intensive Care Transitional Care, Rehabilitation, and Family-Support

"PIC-TRFS is a complex dyadic intervention consisting of 4 essential elements:~1. rehabilitation;~2. health and symptom management;~3. social support;~4. healthcare coordination~It is delivered by an interventionist team via telehealth from the time of randomization at discharge until 6 months after discharge. This Team partners with survivors, families, and the usual care team to deliver the active ingredients of PIC-TRFS."

Dyads randomized to the Control group will receive: (1) the Run-In; (2) an informational brochure on the post-Intensive Care Syndrome; (3) ongoing assessments on the same schedule as the PIC-TRFS intervention; (4) referral for urgent emergent issues identified during the study