Living Well: Transition care helps patients prepare to leave the hospital
Transitioning from hospital inpatient care to home can be a challenging time for patients and their families, but Memorial Regional Health’s transition care services ensure patients are ready when they head home from the hospital.
This transition care, also known as swing bed, is a service where patients can transition from an acute hospital stay to skilled nursing facility-level care, said Kristine Cooper, executive director of Home Health and Hospice at Memorial Regional Health. This care might include services such as physical therapy, IV medication, wound care and other skilled services.
“The team — which includes physicians, nurses, physical therapists, pharmacists, a dietician and case manager — works together with the patient and their family to help ensure as safe transition home,” Cooper said.
Transition care is considered a short-term, skilled nursing and facility-level type of care. The average length of stay is typically one to two weeks, but may be longer if needed, she said.
“Patients that benefit from this type of care have been in the hospital for at least three days, but may not be ready to go home,” Cooper said. “They may need more skilled medical services such as physical therapy, occupational therapy or speech therapy.”
MRH is a hospital in which swing bed utilization is permitted, meaning it can use its beds as needed to provide either acute or skilled nursing (transition) care, according to the Social Security Act. That means MRH can provide post-hospital extended care services, covered by Medicare, in the hospital setting.
Patients are discharged from their “inpatient” status at the hospital, then readmitted as a “transition care patient.” The patient remains in the same hospital room where they were first admitted until it’s time to be discharged from transition care to their home.
Cooper said the goal for transition care is to ensure a safe transition home.
“Therapists work with strength, balance and safety during activities of daily living. Nurses also work with patients, educating them about their condition and medication to make sure patients understand and feel comfortable with what they need to do to stay healthy once they get home,” she said. “Another key part of transition care is the provision of activities such as games, books and other social activities to promote a more holistic approach to getting better.”
Rehabilitation is an essential part of MRH’s transition care services, said Paula Belcher, director of population health management at MRH. In the past year and a half, MRH has invested in its transition care services by growing its rehab staff, she said.
An activities coordinator, another important addition to the staff at MRH, helps keep patients — some of whom are in the hospital for weeks or even months — mentally engaged during their stay.
“The activities coordinator may help a patient use an electronic tablet to listen to music or watch a movie, play games, read a book aloud or take patients for walks (on foot or in wheelchairs) to visit the gift shop or cafeteria so they have a break from the sameness of their hospital room,” Belcher said.
Following are a couple of scenarios that showcase how transition care works:
• Patient is medically cleared to return home but, for a variety of reasons, is not ready to return home, typically because he or she requires some type of rehabilitation to ensure a safe return home. In this instance, a patient may go into transition care to receive rehabilitation services with the intended outcome of returning home.
• Patient is medically cleared to be discharged, but is unable to care for him or herself and therefore needs to be placed in a long-term care facility. In this instance, a patient may go into transition care while a long-term care facility is located and arrangements can be made to transfer the patient.
Patients who qualify for transition care have to be admitted as inpatients for an acute condition and must have a minimum three-day stay in the hospital as an inpatient. This applies to a broad variety of patients of all ages, including those who have undergone complex surgeries or other traumas, stroke patients, patients who have been on ventilators, patients with ongoing wound care needs and patients requiring IV antibiotic treatment. Transition care patients tend to be older adults who have more complex health issues that develop as they age and who are covered by Medicare.
The patient and family play an important role in this transition care, too. Cooper said the care team works with patients and their families prior to being discharged from transition care to consider the various challenges that may arise at home after they are discharged. She said this often includes an evaluation at the patient’s home.
“MRH believes family involvement is essential to a patient’s ultimate success — be it returning home or finding a facility where a family feels their loved one will receive the best possible long-term care,” Belcher said. “Each week, a care team meeting is scheduled at a time when family members can be present to participate in setting goals, track progress, ask questions, celebrate a patient’s wellness journey and be knowledgeable and prepared for what will happen when the patient leaves the care of MRH.”
Belcher said patients who utilize transition care are less likely to be readmitted to the hospital as an inpatient because they’ve had additional time to heal before returning home.
It’s important to note that not only people who were inpatients at MRH can benefit from transition care. If a patient was transferred out of the area for acute inpatient treatment — for instance, to a hospital in Denver or Grand Junction — he or she can return to MRH for transition care.
“We can’t underestimate the value of a person being able to recover in their own community. And it’s not just beneficial to the patient, but the family, too. When a patient receives transition care services in their own community, it lessens the burden on family members by not having to travel long distances to visit recovering family members. That gives peace of mind to both the patient and family.” Belcher said. “MRH has undergone a lot of growth and expansion in services in the past few years. The fact that transition care is one of our improved services is one of the best things we can offer aging members of this community.”
The C.R.A.I.G. Group has selected its final round of grantees for 2019.