Transitional care unit fills a gap in the continuum

Patients need less care, shorter stays

Providing subacute rehabilitation services within an acute care setting eliminates burdensome patient transfers, but not providing post-acute care can be a costly mistake.

When statistics showed that Spaulding Rehabilitation Hospital was turning down potential patients who didn’t need a full complement of rehab services, administrators decided to open a new unit to provide a less intensive level of care.

Six months later, the Boston facility opened its 37-bed transitional care unit (TCU) within the acute care hospital.

"We found that often patients were being referred who didn’t require the intensity of a hospital-level rehab program but who could benefit from our expertise and a short hospital stay. The unit was designed to serve this population," says Susan Glasser, vice president for strategic planning and development.

The unit, which opened in May 1996, has been welcomed by referral sources who now have the convenience of referring all patients who need post-acute care to a single source. Payers like the fact that care in the TCU is about two-thirds the cost of acute rehab. What’s more, patients praise the "homey" atmosphere on the new unit, which is designed to fit the needs of patients who aren’t sick enough for acute rehab.

Spaulding is a 280-bed freestanding rehabilitation hospital with 15 inpatient programs, several satellite outpatient centers, and home health services.

"Our goal and philosophy has always been to respond to all levels of patient needs whether inpatient, outpatient, or home care. This second level of intensity within our inpatient program has been extremely well received by our referral community," Glasser says.

Even the name was chosen to fit in with this philosophy. "We chose a transitional care unit because it describes patients who are in transition between the hospital and the home," Glasser says.

Better continuity of care

In the past, the hospital often had to turn down patients who didn’t need a full complement of rehab services or refer them to a less intensive setting soon after admission. "Our transitional care unit allows them to stay in the same facility and have greater continuity of care. And it allows us to take patients we otherwise might not be able to admit," Glasser adds.

Since the unit opened, the census has increased gradually. Patients who have been referred to the unit include stroke patients, orthopedic patients, and oncology patients who need short-term rehabilitation therapy and some nursing care. They eventually will return home.

"We have made it known to our referral sources that we have the dual capability to admit patients to acute rehab and the transitional care unit," says Eunice Dragone, RN, CNAA, vice president for nursing and administrator for the transitional care unit.

The hospital chose to locate its transitional care unit within the main hospital because there was space available and because the wide array of hospital services could be used for patients if needed. This includes on-site pharmacy and radiology and 24-hour-a-day coverage by physicians who are not always available at freestanding transitional care centers.

80% of acute rehab staffing

The TCU is staffed with about 80% of the staff used for an acute care rehab unit of the same size. Nursing shift hours, however, are slightly less for TCU patients than on the acute rehab unit. Therapy hours vary depending on patient needs. Some need minimal physical therapy but more occupational therapy. Others may have predominately skilled nursing needs, such as wound care or IV therapy.

Staff include physical therapists, occupational therapists, speech and language pathology, recreational therapists, and nurses.

While the staff for the TCU unit is permanently assigned, being a part of an acute rehab hospital gives the flexibility to shift staff over to that unit if the acuity level of patients needs it, Dragone says.

The hospital’s admissions coordinator reviews each case individually to decided whether the TCU or acute rehab would be most appropriate.

Patients with complex or multiple diagnoses, those who need heavy nursing care, intensive therapy, or for whom a longer length of stay is projected, are admitted to acute rehab. Patients who are expected to be discharged to the home after a short length of stay who have singular needs would be appropriate for the TCU.

The TCU uses the same outcomes measures and patient satisfaction tools as the acute rehab component of the hospital.

Six months in the works

Hospital staff planned and opened the unit in just six months. Understanding the complex regulations that transitional care units must follow took up a large portion of the staff’s planning time. Under Massachusetts law, the transitional care unit must be licensed as a skilled nursing facility.

The staff have to be familiar with the Massachu-setts Department of Public Health regulations, as well as those mandated by Medicare and Medicaid.

For instance, regulations governing use of restraints for patients are much stricter for transitional care units than for acute rehab. Skilled nursing facility regulations require that consent forms be given to patients prior to admission and that far more disclosure information be provided before admission than in acute rehab, Dragone says.

"It’s a slightly different way of thinking and a different philosophy," she says. "The regulations are geared toward patients who are going to be in nursing homes for longer period of times, but we still have to operate within them."

To plan the unit, the hospital administration appointed a task force that included representatives of all departments that would be involved in the TCU.

The task force’s job was to keep the staff informed of what was happening, why the hospital chose to open the unit, and what was involved in the process. Subcommittees developed an administrative manual, a residents’ guide, and a policies and procedure manual adapted to meet the SNF regulations.

Comprehensive orientation

The hospital education department, with input from the task force, held a lengthy orientation program for all of the disciplines who were going to be working on the new unit.

To create the transitional care unit, a 37-bed unit was renovated. The size of the unit was dictated by the space available and the state licensure requirements of a minimum of 20 beds.

The space was renovated to include patient rooms, a dining room with a kitchen area that patients and their families may use, a room in which patients can visit with their families, and a therapy gymnasium.

The unit is completely separate from the rest of the hospital as required by state licensure.

The space was redecorated to include carpeting in the corridors, new furniture, and updated lighting to give more of a residential feel than the acute care floors of the hospital.

The hospital’s liaison department representative, who screens patients prior to admission, was instrumental in getting word about the new unit out to discharge planners and case managers in the acute hospitals in the Boston area.

The hospital also hosted a breakfast for referral sources to celebrate the opening of the unit. A state senator was the guest speaker, and guests were given a tour of the unit. An educational program for referral sources was held last fall.