As part of a demonstration project to help hospitalized patients reach a comfortable level of independence before returning home, Jamaica (N.Y.) Hospital Medical Center in Queens opened a seven-bed transitional care unit last November. TCUs can provide assessment and rehabilitation in settings more conducive to and less costly than other types of care while producing greater significant outcomes.
Its essential for patients to feel that they will be able to care for themselves or with the aid of family after discharge, says Laura Lanuza, RN, director of nursing in the TCU. We offer a way for patients to progress from acute care to their home settings by integrating multidisciplinary services during their stay in our unit.
The project, developed by the New York State Department of Health, includes MediSys Health Network and four other state hospitals Champlain Valley Physicians Hospital Medical Center in Plattsburg, Binghamton General Hospital, The Mount Vernon Hospital, and John T. Mather Memorial Hospital in Port Jefferson. Later this year, a six-bed unit in Flushing and a seven-bed unit in Brookdale, also of MediSys Health Network, are scheduled to open.From left, Denise Roman, physical therapist; Ester Nisanova, RN; Alicja Naumowicz, CNA; Jaime La Gennusa, MDS coordinator; Gina Gargano, director of recreation; Ponnamma Varughese, RN, assistant head nurse; Annette Spero, social worker; Laura Lanuza, RN, director of nursing; and Barbara Hartnett, RN, case manager
A Performance Improvement Committee connected to the project will analyze the TCUs in the five pilot hospitals in the state of New York to measure outcomes. The goal of our program is to promote optimal recovery and independence through education, thereby reducing ED visits and preventing re-hospitalizations, Lanuza says.
The hospital-based units serve patients who can benefit from three hours or more of active rehabilitation. They treat patients when their length of stay is exhausted but they are not ready to return home because of clinical complexities and multiple diagnoses. The units were developed as a cost-effective bridge to home or alternative care facilities for patients who no longer are acutely ill. Patients who are unable to function independently upon discharge from the hospital but can perform self-care are good candidates for TCUs.
Patients have comorbidities, Lanuza says. In a hospital setting there are consultants from specialized services who are available at any time to assist with clinical decisions in addition to therapies.
TCUs must be licensed as skilled-nursing facilities to be eligible for Medicare reimbursement. Regulations and standards governing TCUs are the same as those for long-term care facilities and are set by the Health Care Financing Administration and the Joint Commission. According to the Joint Commission, sub-acute care is generally more intensive than traditional nursing facility care and less intensive than acute inpatient care.
For a knee or hip replacement, or similar surgery without comorbidities, the surgical patient will likely be discharged to rehab, Lanuza says. Patients selected for the TCU are mostly medical patients needing continuing medical and nursing care along with various therapies.
Selection criteria for Jamaicas TCU included the need for medical, skilled nursing, and rehabilitation services on a daily basis. Our residents often have multiple disease processes and their needs are medically complicated, says Angelo Canedo, PhD, vice president of physical medicine and rehabilitation services at Jamaica. Canedo submitted the facilitys project proposal to the state.
Jamaicas discharge planning process is designed to return patients to the home setting. Discharge policies and procedures must link patients to home- and community-based providers in the area. The average length of stay on the TCU is five to 21 days.
One RN and one certified aide provide clinical care on the TCU. Another RN also serves as a minimum data set coordinator to assess the patient and formulate a comprehensive care plan that integrates input from all disciplines, such as physical, occupational, speech, and recreational therapies, and nutritional counseling.
Patients undergo daily regimens to keep them busy and productive. All of the therapies and treatments are presented in a patient-educational framework, so that the resident can understand the reason for and the value of their participation in the specific experience.
To reduce injuries and re-hospitalizations, TCUs help patients develop confidence in their abilities to perform tasks before leaving the hospital. A TCU is an interim step for patients with declining self-care functions, Canedo says. Our TCU will help restore these patients to their lifestyles prior to hospitalization, facilitate a safe discharge plan, and reduce their total length of stay all tremendous benefits to our patients and the New York City community.
Canedo and Lanuza are planning research studies to investigate the efficacy and cost effectiveness of this model of care. For information on the pilot, contact the New York State Department of Health at www.health.state.ny.us.