Transitional care has emerged as a way to reduce hospital readmissions, and progressive care nurses can play an integral role in efforts to help patients achieve functional recovery faster in post-acute care, according to an article in the June issue of Critical Care Nurse.
The article, “Progressive Mobility as a Team Effort in Transitional Care,” reviews post-acute transitional care as provided at a skilled nursing facility in western New York and examines the individual roles of various interdisciplinary team members, including progressive care nurses.
Patients recently discharged from the hospital may move to a transitional care facility as they strive to regain their functional abilities and independence.
Their diverse conditions may include congestive heart failure, chronic obstructive pulmonary disease, pneumonia and postoperative debility, all requiring skilled nursing and rehabilitation.
“With the increased focus on reducing readmissions, it has become imperative for all members of the interprofessional team to coordinate plans of care for each patient in transitional care,” said lead author Margaret Ecklund, MS, RN, CCRN, ACNP-BC.
Ecklund is a lead advanced practice nurse for the complex care transitional program in the Rochester (N.Y.) General Health System.
In the article, she discusses the importance of interdisciplinary team strategies for incorporating progressive mobility and functional independence into the daily routines of transitional care patients.
Mobility is a core component of patients’ care plans and a crucial element of their being discharged home. It is also a key indicator for insurance coverage for post-acute stay at a transitional care facility.
“Mobility gets woven into the fabric of daily activity, rounds and plan of care,” Ecklund said. “In a culture of progressive mobility, team members hold one another accountable for their roles in safe mobility.”