From left, Katherine OSullivan, RN, nurse informatics; Betty Lagitch, RN, manager, medical surgical; and Bonnie Michaels, RN, vice president and CNO, use creative visuals to describe an initiative.
The 18-bed transitional care unit at HackensackUMC Mountainside Hospital, Montclair, N.J., provides short-term rehabilitation and skilled nursing care with a maximum length of stay of eight days.
As one of only six of its kind in the state, the unit serves adult patients who have had orthopedic surgery or been diagnosed with cardiac or respiratory disorders that require rehabilitation.
Ninety-five percent of their patients come from the Mountainside inpatient units, and all patients are screened before transfer or admission, according to Lisa Hertel, RN,C, director of subacute services. Patients also may be admitted to the unit from the community but they must have had acute care hospitalization within 30 days.
“Because of our shortened [length of stay], we dont want to set up unrealistic expectations, and all patients are screened with the hope that they meet our criteria and can benefit from a stay with us,” said Hertel, whose TCUs preadmission screening tool is used to ensure compliance with inclusionary diagnoses, possession of skilled nursing care, Medicare criteria and insurance authorization, and also includes a review of prior level of function, current level of function, and the ability to be discharged to the environment before hospitalization.
TCUs such as Mountainsides provide an appropriate level of care while not transferring patients to other facilities unnecessarily.
“We can provide outcome-oriented, patient-focused care and treatment either immediately after or instead of a hospitalization,” Hertel said.
Patients are encouraged to dress and shower every morning and to achieve their highest level of function, with a focus on activities of daily living, ambulation, gait training and energy conservation.
In an effort to decrease readmission rates, Hertel and staff focus their efforts on patient education with a number of nurse-driven initiatives.
On admission, every patient is assessed for their risk for readmission. Using eight “triggers,” a holistic treatment plan is developed. Based on the treatment plan, the patient and family are educated on developing and maintaining a healthy lifestyle and a maximum level of independence. The eight triggers that are used to guide the treatment plan include polypharmacy; problem medications (for example, anticoagulants, diuretics, narcotics); psychological history; primary diagnosis of heart failure, pneumonia, acute MI or COPD; poor health literacy; need for a caregiver; nonelective admission within six months; and advanced chronic illness.
On admission and throughout their stay, patients are educated about their medications and, before discharge, staff review medications with the patient and a family member.
At the midpoint of the stay, the interdisciplinary team meets with each patient and family members to discuss the patients progress, along with present and future goals. “Because everyone is involved in the process, including nursing, social work, rehab and medical staff, patients can ask questions, and upon discharge they will leave our unit knowing exactly what to expect in terms of home care or outpatient follow up,” Hertel said.
Unlike any other state, New Jerseys legislation imposes unique restrictions on hospital-based TCUs that include a maximum LOS of eight days and exclusionary diagnostic categories. Despite these restrictions, the TCU at Mountainside has received a five-star rating and a deficiency-free survey from the Centers for Medicare and Medicaid Services, and is rated in the top 10% of nursing homes nationwide, according to Hertel,
“We have professionals who take ownership of the unit and are dedicated to excellence in patient care,” Hertel said. “Many of our patients are elderly, and our staff is committed to improving their quality of life before they are discharged.”
Janice Petrella Lynch, RN, MSN, is a regional nurse executive.