When you leave the hospital following treatment of an acute condition, you may require ongoing care for a chronic medical condition, as well as assistance with your day-to-day routine. Your care may necessitate special equipment or services. In these situations, a transitional care unit provides supportive care, and promotes safe and timely passage across care settings.
A transitional care unit is, most often, a short-term care facility (less than 21 days) for medically complex patients transitioning from the hospital to home, or from one care setting and to another. The goal of the transitional care unit is to assist in recovery by providing the nursing and rehabilitative care necessary to help you or your family member regain a certain level of independence.
Depending on the condition, the care may include:
High-quality transitional care is especially critical for older people with complex or chronic conditions and for their family caregivers. It should be noted that to qualify for admission to a transitional care unit, patients must be able to participate in daily intensive rehabilitation therapy with the ultimate goal of restoring their maximum level of functioning and fitness.
The primary benefit of a transitional care unit is that it provides coordination and continuity during transitions between different locations or levels of care. It bridges the gap between various providers, services, and settings, and — ideally — provides education about the next stage of recovery for you, your loved one, and your family.
Transitional-care programs also significantly lower readmission rates, due in part to an array of comprehensive services aimed at improving the transition to home, such as medication evaluation and optimization, patient and family education, social services or discharge planning, individual home-exercise programs, visiting-nurse arrangements, post-discharge outreach, home visits, and primary care provider follow-up.
Unlike community-based sub-acute care facilities, which have limited medical resuscitation equipment or the staff trained to use it, transitional care units have immediate access to acute resuscitation services. Because transitional care units are hospital-based rather than community-based, their radiology and laboratory facilities are located on site. In addition, transitional care units have an on-site medical doctor 24 hours a day, as well as access to all tertiary-care specialties.
The availability of multidisciplinary care is one of the main reasons why transitional care units are capable of caring for patients with multiple complex conditions. The expansive rehabilitation services they offer, such as physical therapy and occupational therapy, are especially valuable for patients recovering from orthopedic procedures such as joint replacement or fracture reduction.
If you or your loved one would benefit from short-term, ongoing specialized medical services and rehabilitation following a hospitalization and are not yet appropriate for discharge, a transitional care unit may be an ideal option.
The continuity of care and broad range of services provided effectively bridge the gap between acute care and discharge. They lower the risk for hospital readmission, reduce complications related to transfer of care, and improve patient satisfaction. Transitional care units are a mode of intermediate rehabilitative care dedicated to facilitating a safe discharge home or to another facility, enabling patients to resume a more active and fulfilling life.
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