Memorial Regional Health: After an inpatient hospital stay, heading home requires help — MRH expands transition care services to ensure patients leave hospital setting with tools needed to succeed at home
January 31, 2019
Editor's note: The following article is sponsored by Memorial Regional Health.
Transitioning from hospital inpatient care to home can be a challenging time for patients who are already dealing with so much. This is why Memorial Regional Health has expanded its transition care services to ensure patients have everything they need when they head home from the hospital.
"In previous years, MRH didn't have the depth and breadth of rehabilitation services for transition care as it now does; without rehab, transition care falls flat," said Paula Davison, director of population health management at MRH. "In the past year, MRH has invested in its transition care services by growing its rehab staff."
A new 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," Davison said.
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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 care (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." Davison said the patient remains in the same hospital room where they were first admitted until it's time to be discharged from transition care to home.
The team of staff involved in this important transition care includes social workers, rehabilitation services (including occupational, physical and speech therapy), respiratory therapists, pharmacists, physicians, nurses, certified nursing assistants, a registered dietician, activities coordinator, discharge planners, and the director of population health. The patient and family play a role, too.
"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," Davison said. "Each week, a care team meeting is scheduled at a time when family members can be present to participate in setting goals, tracking 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."
Patients who qualify for transition care would have to be admitted as inpatients for an acute condition and 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.
Following are a couple of scenarios for how it 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.
Davison 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." Davison 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."