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The Value of Transitional Care

By EmpowHER November 1, 2011 - 12:12pm

A Transitional Care Unit (TCU) is a short-term intensive rehabilitation facility that is typically a bridge between a hospital stay and returning home. It differs from a traditional nursing care center in several ways: First, the length of stay tends to be shorter, typically 21 to 33 days, and second, the type of rehabilitative care is more intensive. It is not unusual for patients in a TCU to receive up to three hours of rehabilitative therapy each day.

Good transitional care helps patients achieve better outcomes and reduce costs, according to a study published by Journal of Evaluation in Clinical Practice.

When comparing patients before and after TCU therapy, researchers found significant improvement in the patients’ functional status, depression, symptom status, self-reported health, and quality of life. Patients and doctors interviewed for the study reported a high level of satisfaction with TCU care and results showed a significant reduction in hospital readmissions three months after TCU enrollment, as well as a decrease in total health care costs of $439 per person per month.

It’s common for most people to think of “rehabilitation” as “physical therapy” but in reality it is much more. Rehabilitation is a wide variety of medical, psychological and physiological services to help one restore good health, function, strength, mobility, cognitive ability and usefulness in society.

Rehabilitation services are typically ordered by a doctor to help a patient recover from an illness or injury. Nurses and physical, occupational and speech therapists and social workers or case managers, as well as other health care professionals deliver these services.

Rehabilitation is critical to the healing process and often serves as a component of a greater health care plan. For patients well enough to be discharged from the hospital, but not yet ready to return home, inpatient rehabilitative care offers a safe and supportive transition. Your rehabilitation team works together to devise, implement and monitor therapy plans tailored to the specific needs of each patient.

This multidisciplinary approach fosters active participation and helps ensure the highest level of physical, emotional and psychological support so patients can successfully advance through the rehab process.

Patient support is an important part of the rehabilitation process. Most healthcare professionals agree a patient’s support network is crucial to maintaining results achieved through a formal rehabilitation program and help ensure long-term success, so don’t be surprised when your family, close friends or caregivers are invited to join your rehab team.

It is important for patients to know change doesn’t happen overnight. Setting realistic goals helps patients—and their caregivers—to expect slow, steady progress and to better understand the steps, skills and support needed in reaching their goals. To avoid frustration and/or disappointment, patients and their caregivers should know what performance outcomes to expect from their rehabilitation therapies and establish realistic goals, according to a study published in Annals of Long-term Care. Your care team will be happy to discuss this with you and your support team before you begin your rehab program.

Sources:

National Center for Rehabilitation Research (NCMRR). Eunice Kennedy Shriver National Institute of Child Health & Human Development website, part of the National Institutes of Health. Accessed 10 October 2011 at:
http://www.nichd.nih.gov/about/org/ncmrr/

M. D. Naylor, K. H. Bowles, K. M. McCauley et al., "High-Value Transitional Care: Translation of Research into Practice," Journal of Evaluation in Clinical Practice, published online March 16, 2011. Accessed 10 October 2011 at:
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2011.01659.x/abstract

National Institutes of Health Clinical Center website, accessed 10 October 2011 at:
http://clinicalcenter.nih.gov/rmd/

Patient and Caregiver Rehabilitation Questions. Eric M. Coleman MD, MPH, and Peter D. Fox, Ph.D. on behalf of the HMO Care Management Workgroup, Published in the Annals of Long-term Care, Vol. 12, No. 10, Oct. 2004. Accessed online 10 October 2011 at: http://www.annalsoflongtermcare.com/article/3409?page=0,3

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