Northwell Mather Hospital has a special unit designed to help complex patients discharge straight home after only two weeks.
In 2007, the Port Jefferson, N.Y.-based hospital opened a transitional care unit as part of a demonstration program ran across the state of New York, Carolyn Germaine, MSN, RN, director of patient care in the transitional care unit, told Becker’s. The transitional care unit includes 16 beds and provides physical therapy, occupational therapy, speech therapy and recreational therapy seven days a week. It serves wound care, joint replacement and complex patients who are not ready to return home and are not ready for skilled nursing facilities. Nurses provide all the care on the unit and have an 8-to-1 patient ratio. Although the unit is located in the hospital’s old pediatric wing, it has a separate operating license from the hospital.
On average, patients stay about 13 days, and 86% are discharged to home. The remaining 14% either discharge to a skilled nursing facility or hospice. The average age of patients in the TCU are 83, though the unit regularly serves patients in their 90s and 100s.
One of the most impactful tools the unit uses is a bedside meeting with family within the first three to five days of admissions. Here, families meet with nursing, PT, OT, dietary, social work and, when available, the physician to discuss what the family needs additional help with.
“We ask the family, What is it that you need from us?,” Ms. Germaine said. “What learning needs are you missing? What would make the transition home better for you? What’s been an obstacle to getting home in the past, or staying home once you get there? Those conversations have driven our satisfaction scores — we’re running about 95% ‘would recommend the facility’ right now, 10 points over last year.”
The unit has also helped cut readmissions for these complex patients. In 2017, the readmission rate for the unit was 25%. Since then, Ms. Germaine has worked closely with hospital teams to find the root causes of readmission and cut down the readmission rate to 7%.
One of the most common readmission issues was related to medication reconciliation.
“That’s a big issue in most post-acute care,” she said. “We did a lot of education with the staff and the hospitalists who come through this unit on which medications to avoid. We have a pharmacist on rounds with us every morning, and the pharmacist will point things out, and we’ll try to de-escalate some of the heavier medications patients are placed on.”
Despite the unit’s success, the state has stopped giving out licenses for these types of units, Ms. Germaine said, and there are only five left in the entire state.
“These units are Medicare, managed Medicare and insurance only when they were set up — there’s no Medicaid component; you can’t bill Medicaid through this type of unit,” she said. “My hope was always that these units would grow at other facilities, because they really do keep patients out of long-term care facilities.”
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