Living Well: Transition care services: Helping patients recover, go home
August 21, 2018
If you've ever had a condition that demanded recovery time, you can understand why having a supportive team in the hospital that helps you get stronger and regain independence is an important part of your journey to returning home. At Memorial Regional Health, this service is called Transition Care.
Patients often need Transition Care after they've had a surgery, injury, or illness that demands intense rehabilitation — more than can be given on an outpatient basis. The goal is always to continually improve, with the ultimate goal of going home. Time in Transition Care varies depending on the need but can last from a few weeks to a few months. It's helpful to receive Transition Care here in Craig, where you have your loved ones nearby, which is an option even if you receive acute care elsewhere.
"If a patient receives care in Denver or Grand Junction, they are already in a difficult situation, so to remove them from their hometown and their support system makes it harder for them to heal," said Nancy Cadenhead, RN, patient care planner.
The Transition Care team is made up of nurses, hospitalists, physical therapists, occupational therapists, speech therapists, registered dieticians, respiratory therapists, patient care planners, and soon, an activities coordinator. Team members coordinate their services to help patients meet their recovery goals.
"We hold weekly meetings with the patient and family, the Transition Care team, and the patient's doctor to discuss how we can best help the patient meet short-term goals each day, so patients can reach the ultimate goal of going home," said Paula Davison, population health director.
Two new additions have the Transition Care team excited: A new outside patio is coming soon, and an activities coordinator is joining the staff. The activities coordinator will get patients out and about from their room, help them get meals in the cafeteria, and engage in social activities.
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"The outdoor patio is located on the same wing and should be open in the near future," Davison said. "We've laid the concrete and are getting furniture. It will let patients get out in the sunshine and also visit with their pets. Weather permitting, we hope it can be open year-round."
In Transition Care, the focus shifts from doing for patients to helping them become independent and self-sufficient and doing for themselves. That way, they get home quicker. If needed, the Transition Care team can set patients up with home health care if they still need a little help.
The team sets patients up for success upon discharge by giving follow-up calls in the first few days and the following week to answer any questions they might have. They also set up follow-up appointments with their physicians, if desired.
"Our patients are always welcome to call Patient Care Planning after they go home if they have questions about anything," Cadenhead said.
To learn more about Transition Care at MRH, call Nancy at 970-826-3234 or visit memorialregionalhealth.com.