Beyond the Hospital Walls: Transitional Care

With the ever changing climate of healthcare, now more than ever there is a stress on hospitals to decrease patients’ length of stay (LOS). Patients expect to be seen quicker, get well faster and discharge as soon as possible. Hospitals are also working to treat patients and discharge them sooner. While this causes an increased challenge to the hospital, it allows for an even greater opportunity for facilities that receive patients after their hospital stay. This opportunity being the ability to provide transitional care.

Transitional medicine (TM) is the coordination and continuity of patient care beyond the hospital doors. Any transition of care from a hospital to another healthcare facility other than home is classified as transitional medicine.

With the increasing demand on hospitals to get patients home faster, it is important that hospitals and health systems have the knowledge of how transitional medicine works and are partnered with a group like ApolloMD that can provide that continuum of care. Learn more about how the transition process works and the facilities where patients receive care.


How It Works

Once a patient is admitted into the hospital, the clock starts ticking on their LOS. Complex medical conditions and intensive rehabilitation needs often add to LOS offering transitional medicine as a solution. Upon discharge, patients are:

  • Sent home feeling better with no additional care needed
  • Sent home with the plan of receiving home healthcare
  • Continue care at a TM facility

Physicians consult with patients and their families on the level of care that is needed to determine the best option for the patient’s next steps.

Independent Living Facility (ILF) and Assisted Living Facility (ALF)

Facilities providing the least amount of care include independent living facilities (ILF) and assisted living facilities (ALF). These facilities focus more on assisting daily task, living needs, providing meals and providing meals.

ILFs: Patients can still live independently but have access to assistance when it is needed. ILF’s offer the geriatric population with sufficient means, whether through savings or benefits, to participate in active planning and anticipation for future needs.

ALFs: Patients benefit from community style living with added assistance. An ALF houses onsite offices for physical therapy and “house calls” from physicians and APCs. ALFs are almost universally comprised of retirees, usually in the geriatric stages of life. A majority of residents range from 70 to 90 years old with an average age of 80.

Skilled Nursing Facility (SNF)

The next option for patients is a skilled nursing facility (SNF), which is often referred to as a nursing home or rehab. These facilities provide a higher and more skilled level of medical care than an ILF or ALF. This type of facility provides 24-hour care and patients are seen anywhere from two times per month to as often as once a day, depending on the patient’s needs. SNFs include hospice care, long term and skilled care.

Inpatient Rehab Facility (IRF) and Long Term Acute Care Facility (LTAC)

Patients who need the highest level of care often transition into an inpatient rehab facility (IRF) or a long term acute care facility (LTAC).

IRFs provide patients with a high level of intensive therapy, as well as specialized nursing and physician care. For admission into an IRF, patients must meet Medicare or private insurance eligibility requirements. Those admitted receive treatment from a multidisciplinary team of physicians, nurses, case managers and therapist. Patients are closely supervised by a physician with specialized training, receive 24-hour rehabilitation nursing and daily rehab therapy.

LTACs provide the highest level of care for patients with complex medical conditions and intense, specialized rehabilitation and treatment. Patients receive treatment from a team of highly skilled physicians, APCs, case managers and therapist over an extended period of time. Specialized oncology, wound and cardiac care is provided, along with multiple over service areas.

Multiple Levels of Benefits

Benefits of transitional care can be seen on multiple levels starting with the patient. Patients receive healthcare tailored to their needs. Those with complex medical conditions in need of rehab have the option to receive care in one setting rather than jumping from appointment to appointment with various specialists.

Residents, physicians and advanced practice clinicians (APCs) benefit through the option of a new opportunity or a chance for education and growth with TM. In transitional care, a particular emphasis is placed on the emerging roll of APCs. While patients see and communicate with the physicians, APCs are seen as the cornerstone of the delivery of care in TM. The high-level skill set and compassion provided by APCs is an added benefit for patients.

From the hospital and health system standpoint, there is availability in continuity of care. Hospitals see decreased LOS percentages, better patient outcomes, improved communication and decreased re-admission percentages when patients elect to receive transitional care.

Serving as the bridge from the hospital to home, TM facilities nationwide are partnering with groups like ApolloMD to provide their patients with this continuum of care.­­­­­­­­­­­­­­­­­­

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