Transitional Care: Delivering Better Outcomes for Medically Complex Patients

It’s been called the “boomerang effect”—patients discharged from the hospital who bounce right back for readmission. Almost 20 percent of discharged Medicare patients are readmitted within 30 days at an annual cost of $15 billion to $20 billion. Often the cause of readmission is patients being discharged before they’re ready or transitioning to an environment, such as the home, where their medically complex needs cannot be adequately met.

Over the past several years, the federal government and the healthcare industry have maintained a laser focus on preventing avoidable readmissions. The goal is to lower healthcare costs and improve quality of life for discharged patients, many of whom have multiple chronic conditions. In the vulnerable transition from the hospital to the next care setting, these patients need closely coordinated, continuously monitored care.

Gauging the options

Finding the most appropriate setting of care after hospitalization involves assessing patient needs and matching them with the capabilities of potential post-acute providers, such as skilled nursing and rehabilitation facilities.

“It’s often difficult for a patient who’s had surgery to return right away to the home environment,” says Dianne Sullivan-Slazyk, chief nursing officer at StoneGate Senior Living, a leading provider of rehabilitation, skilled nursing, assisted living, and memory care services.  A recent study found that more than half of the elderly patients discharged from the hospital feel they’re not ready to go home.

“Patients may be in a weakened state, may be taking numerous medications, and may be managing several chronic conditions,” Sullivan-Slazyk says. “Our facilities help bridge the gap between hospital and home, bringing patients to a baseline where they’re functionally safe to be home again.”

Getting off to the right start

“Getting discharged patients off to a right start is key to their renewed strength and long-term well-being,” says Natalie Hooper, chief operating officer at Rehab Pro, a leading provider of rehab services. “Short-stay facilities provide a protective setting for patients in their first days of recovery and can have a huge impact on the outcomes they have down the road. Instead of waiting for a scheduled visit from a home health nurse, they have 24×7 access to nursing care. They also have physical therapists and occupational therapists working with them every day. Their medications are closely monitored, their pain is well managed, they enjoy regular nutritious meals, and they receive education on their condition and potential complications.”

For patients recovering from orthopedic surgery, beginning intensive rehab and mobility training immediately is particularly important. “Often when patients go home right after surgery, they’re reluctant to move around the house and begin to do things for themselves,” Hooper notes. “This starts a cycle of pain, limits activities, and can cause a downward spiral in their health outcomes. When they’re in a transitional facility, they know the sole purpose of their stay is rehab. With a full care team supporting them, they’re highly motivated to regain their strength and mobility so they can quickly resume a normal life.”

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Guiding staff to manage complications

Key to success in post-acute care (PAC) is training staff to identify the early warning signs of patient complications. “Patients need to be closely monitored for any worsening of a current condition, the presence of wounds, or the development of pneumonia or sepsis,” says Sullivan-Slazyk.

“Early detection and intervention are critical to mitigating or minimizing adverse events. It’s a comfort to patients and their families to know a team with specialized training is watching the patient continuously, as opposed to once a day in a 20-minute home visit.”

Gaining the full picture

PAC providers offer the advantage of interdisciplinary teams that coordinate care and consider each patient’s full medical history.

“A patient who enters one of our facilities to recover from a knee replacement may be living with several other health challenges that need to be managed,” says Hooper. “For example, they may have diabetes, hypertension, or heart disease. The inpatient setting is better equipped to assess how comorbidities affect patient rehab—and to make sure patients don’t have a return to acute care because of these other underlying issues.”

“We also look beyond medical needs to patients’ nonmedical challenges and social issues,” adds Sullivan-Slazyk. “For example, does the patient have a caregiver at home? Access to food delivery? In-home physical barriers, such as steps? Our care teams address any factors that could impede a full recovery when patients leave the PAC setting.”

Giving thorough instructions

Another key to successful care transitions is sharing thorough and accurate patient information—from provider to patient and from one caregiver to the next. “It’s all about communication, communication, communication,” Sullivan-Slazyk says. “That’s so important in transitioning patients from the hospital to post-acute care, from post-acute to home health, and from home health to an outpatient setting.”

A major reason for hospital readmission is a lack of medicine reconciliation—and of confirmation that patients have the means to pick up their medicines and pay for them. “We make sure patients leave with enough medications to last through their next physician appointment,” Sullivan-Slazyk says. “Often, that process is skipped in the direct transition from hospital to home.”

Growing the care team

“In choosing the best PAC providers, hospitals should look beyond Medicare Star ratings to consider such factors as patient acuity level, staffing patterns for nursing and rehab, staff training programs, types of patient activities, wellness plans, and overall track record for getting patients home without incident,” Sullivan-Slazyk says.

“In recent years, collaborative, coordinated care among all parts of the delivery system is no longer the exception. It’s the expectation,” Hooper adds. “Whatever our role in the care continuum, our shared goal is to help patients transition safely and seamlessly from one care setting to the next—improving their likelihood of success at every point of their healthcare journey.”

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