So I ran 7 miles this morning with a friend. I told him I needed material for a blog entry and asked him if he wanted to be my sounding board.
He said no, thanks I’m busy!
‘Course that didn’t stop me, so I launched into what I’m sure was a terribly boring (to him) monologue on the topic of “transitional care.”
(yeah, I know, great stuff at 7 in the morning and excellent motivation for a runner, sheesh!)
The point is, in the Healthcare industry, there is an increasing desire to throw around terms like “transitional care” “acute care” “post acute care” “sub acute care” “skilled care” – etc. If these terms prove to be difficult for a professional to distinguish, imagine what the layman must feel like.
Patients in the hospital often receive “acute rehab” and are encouraged to pursue sub-acute rehab in a skilled nursing facility upon discharge. Some rehab facilities call it sub acute and some call it post acute and those “differences” are more semantic than substantive.
So what does it all mean and where does it all begin?
I think it all begins with “Transitional Care.”
Transitional care refers to a scientific model comprised of multiple components. Within the framework of transitional care, exists “acute rehab” “post/sub acute rehab” and “long term skilled nursing care.”
Simply put, patients will transition from one phase of care to another beginning with the initial hospitalization and ending with their discharge from an in-patient rehab facility to home, or culminating with their long term placement in a nursing home.
Healthcare providers are given a mandate to ensure the continuity of care during (what should be) this fluid transition. The fact is, a patients’ condition and care needs will change during the course of a chronic or acute illness.
During a transition, patients are always at increased risk for a poor outcome, if the provider(s) cannot safely steer them from the acute to post acute and skilled nursing settings. Poor outcomes, usually include a readmission to the hospital which is otherwise known as a “re-hospitalization” (a very hot button topic in our industry, as I previously blogged about here)
American Geriatrics Society defines transitional care as follows:
“For the purpose of this position statement, transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing homes, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.”
I hope this article helps clarify some of these terms and of course, look us up at www.RegencyNursing.com for the most comprehensive transitional care available!
All of this from 7 miles running.
Imagine if I’d have gone for 15….