Refer a post-transplant patient back to secondary care for further evaluation if they show signs of slower than expected recovery or develop new or unexpected complications related to their transplant.
This includes situations where the patient is not meeting their rehabilitation goals or has developed unanticipated physical or non-physical morbidity that was not previously identified during their recovery phase.
Ensure that a functional reassessment is performed, ideally face to face by a healthcare professional familiar with the patient’s transplant and rehabilitation pathway, typically 2 to 3 months after discharge from critical care or hospital.
Additionally, if there are concerns about mental health issues such as anxiety, depression, or post-traumatic stress disorder, referral to appropriate specialist services should be considered.
In summary, referral back to secondary care is warranted when the patient’s recovery trajectory deviates from expectations or new complications arise that require specialist input.
This approach aligns with NICE recommendations on rehabilitation after critical illness and ongoing management of complex patients.
References: NICE CG83