Short-Stay Transitional Care: Jumpstarting Recovery

If you or your loved one has been discharged from the hospital, ensuring a continued high level of care is key to regaining health, strength, and mobility. Short-stay transitional care facilities provide medical follow-up for patients in their first days after a hospital stay – and can make all the difference between a successful return to home or a rebound to acute care.

“At a short-stay transitional care facility, patients have round-the-clock access to team-based care,” says Dr. Rajendra Kadari, a Colorado-based internal medicine physician. Dr. Kadari is also the medical director for Accel at Golden Ridge, a provider of transitional care and rehabilitation services. The 60,000-square-foot facility was opened in spring 2017. It is one of 43 communities operated by StoneGate Senior Living, a leading provider of rehabilitation, skilled nursing, assisted living, and memory care services.

Closing the care gap

“With today’s focus on cost containment, many patients are being discharged from the hospital faster, sometimes before they are fully recovered,” Dr. Kadari says. “Their medical problem has been addressed, but they’re still on the mend. They need continuous care – from ongoing monitoring and pain management to physical therapy and nutritional guidance. I’ve seen many cases where a patient goes home prematurely, declines, and ends up back in the hospital. Or, they may have become so weak from hospitalization that they fall, injure themselves, and again, return to the hospital. A minor problem can rapidly escalate into a bigger one.”

Dr. Kadari offers the example of a patient who had a knee replacement and felt she was strong enough to go home from the hospital immediately. But once home, she stepped on her leg the wrong way and ended up with her knee wound reopening. “She had to have her surgery redone,” he notes, “and came into our care after her second hospitalization to recover. She regretted her hastiness in returning home after the first operation – and wished she’d taken the time for supervised rehabilitation.

Comprehensive rehab services can close the care gap, increasing the patient’s chances of a successful return home and decreasing transfers back to acute care. A collaborative team coordinates care, closely monitors medications, and coaches the patient in how to manage pain and regain maximum function.”

Conferring with the patient and family

“After a patient is admitted to our facility, every member of our care team – from physicians and nurses to physical therapists and dieticians – meets with the patient and their family members in a ‘care conference,’” Dr. Kadari explains. “Together, we address the key questions affecting recovery. What are the patient’s goals? What challenges do they face? What is their estimated length of stay with us? What are the possibilities and limitations of the care we provide? We make sure the patient and their family get the full picture so that they have realistic expectations, are fully engaged in the healing process, and can make the best choices.”

Dr. Kadari tells the story of a patient with a history of chronic lung disease. “He contracted pneumonia, had to be hospitalized, and ended up with a breathing tube in his throat. When he was admitted to our facility, he had survived a trip to death’s door. But 20 days after being with us, he was an entirely different person – cracking jokes, talking up a storm, and loving life. We released him to home on day 21, knowing his prognosis was excellent for the way forward.”

Choosing the right facility

A strong recovery hinges on selecting the right transitional care provider. Five-star quality ratings – developed by the federal government to help consumers compare post-acute care facilities – are a starting point for assessing options. From there, patients and their families need to look “under the hood” to identify the care provider’s strengths and weaknesses.

The quickest route to an informed decision? Taking a tour of the building, Dr. Kadari advises. “If you see more nurses in patient rooms than at the nurses’ station, that’s a good sign. If you’ve been caring for a loved one at home and are seeking respite care, make sure the staff is highly experienced in treating the condition your loved one has.

“Ask what the care provider is best at doing. Every facility has its strengths and weaknesses. For example, at Accel, our greatest strength is in managing medically complex cases and pain issues. We are particularly successful in treating joint replacement and spinal cord injury patients – and have a close relationship with Panorama Orthopedic and Spine Center in Golden, one of the nation’s largest orthopedic groups.”

Considering the location

“Often, family members are most concerned about the driving distance from their home to the rehab facility,” Dr. Kadari says. “They may lean toward choosing the provider that’s most conveniently located. I caution them, ‘It may be an hour’s drive for you, but consider this: for your loved one, it’s a 24-hour-a-day experience. Much more important than a short drive to the building is a short distance to recovery.’”

CONTACT US to learn more about high-level transitional rehabilitation services for your patient or loved one. Help them regain health, strength, and mobility – and find the path forward to long-term well-being.