If you or a loved one are being discharged from the hospital but are not ready to return home, a transitional care unit may be right for you. A transitional care unit provides medical care that is more complex than home health and outpatient follow-up clinics can provide. This article will discuss the basics of transitional care units, what patients benefit from them, how to get admitted, and what you can expect once admitted.
What is a Transitional Care Unit?
Transitional care units are a type of short-term-care facility, patients are usually admitted to them for 21 days or less. Transitional care units often have many of the same medical doctors, therapists, and support staff as hospitals. The main difference between a hospital and a transitional care unit is that the transitional care unit will not have many of the medical imaging and laboratory testing capabilities used to evaluate unstable patients in the hospital.
Transitional care units often act as a middle step between hospitals and lower levels of care, such as subacute rehabilitation, skilled nursing facilities, and assisted living. Transitional care units have more nurses per patient and more medical resources if a patient’s condition unexpectedly worsens.
Unlike subacute rehabilitation and skilled nursing facilities, patients are rarely ready to return home after a stay in a transitional care unit. Patients admitted to these units are often still in fragile condition, heavily dependent upon skilled medical care. The goal of a transitional care unit is generally to observe the patient outside of the hospital environment, ensuring that their condition does not worsen during treatment. Admission to a transitional care unit is almost always followed by discharge to a skilled nursing facility or other live-in facility.
Services in a transitional care unit
Transitional care units can offer many of the same services as larger hospitals. These services are focused on maintaining and improving the health of patients who have already been treated and stabilized by a hospital. Some of the most common services offered by transitional care units are:
- 24/7 access to on-site doctors
- Skilled nursing care
- Physical therapy
- Occupational therapy
- Speech therapy
- Social work and case management
- Nutritional and dietary specialists
- Ventilator management
- Wound care
- Intravenous medications and fluids
- Feeding tube, colostomy, and tracheostomy care
Physical, occupational, and speech therapy are some of the most critical services in transitional care units. Patients must rebuild their skills, strength, and coordination after severe illness or injury. Starting this process as soon as possible is critical for recovery, as delays in starting therapy are associated with worse patient outcomes. A good transitional care unit will offer regular therapy, often more frequent and intense than what is available in the hospital.
Where are Transitional Care Units Located?
Transitional care units may be stand-alone facilities with their own staff, or they may be affiliated with a larger hospital or hospital network and utilize their medical staff. Many transitional care units are built near hospitals, rehabilitation centers, nursing homes, and other healthcare facilities.
The term “transitional care unit” is sometimes used to refer to step-down units within the hospital. A Step-down unit is for patients within a hospital moving from an intensive care unit to a regular hospital room. The transitional care units discussed in this article are different; they provide a place for patients treated and stabilized by a hospital with too many medical needs to return home safely.
What Patients Need a Transitional Care Unit?
Many medical conditions can benefit from transitional care at the time of discharge from the hospital. Some of the most common are:
- Stroke (cerebrovascular accident)
- Heart attack (myocardial infarction)
- Catastrophic Injury
- Traumatic brain injury
- Spinal cord injury
- Respiratory failure
- Sepsis (severe infection)
Every patient is unique, some patients experiencing the conditions on this list may require little to no care once they leave the hospital, while others may require an extended stay in a transitional care unit. Patients with multiple chronic medical conditions may require transitional care unit admission after hospitalization for even minor illnesses.
Transitional care units are typically used to care for patients with complex medical needs dependent upon medical equipment, intravenous medications, and a team of specialists. However, many less medically complex patients can also benefit from additional care after discharge from the hospital. These patients are typically referred to subacute care, where they can receive daily therapy and rapid follow-up. For more details, see our article on subacute care.
Admission to A Transitional Care Unit
Case managers usually handle admitting a patient to a transitional care unit. Case managers working for the hospital, transitional care unit, and insurance agencies work together to determine which facility is most appropriate for the patient. Admission to a transitional care unit typically occurs in four main steps:
- Stabilization: Treatment of the condition that led to hospital admission. Focused on discovering and treating any life-threatening conditions.
- Discharge planning: Determining a patient’s needs outside of the hospital setting.
- Facility selection: Comparing the needs of the patient to the level of care that nearby facilities can provide.
- Transport: Arranging for safe transportation to the patient’s new facility after hospital discharge.
Costs of transitional care
The cost of a transitional care unit is almost always covered by insurance. Transitional care is much less expensive than remaining in the hospital for additional days or needing to be re-admitted due to a worsening medical condition after discharge home. Transitional care units have skilled case managers who communicate with insurance companies and remove this burden from patients and families. This financial benefit, combined with the work of case managers, makes insurance-related issues uncommon in transitional care.
Sierra Care and Transitional Care Services
There are many options for transitional care after hospital discharge. It is critical to choose a facility that provides you or your loved one with the best possible care following hospital discharge. Sierra Care has several facilities in central California that provide transitional care, subacute care, and rehabilitation services. We differ from typical transitional care providers in that we offer many levels of care, simplifying the recovery process. Our case managers follow patients through their entire recovery, helping to plan the admission process and transfers between levels of care. This reduces the burden on patients and families, allowing patients to focus on recovery. For more information, contact us to speak with our case management team!
