Welcome the Transitionalists – the newest team on the block!

January 25, 2017 by   |   Leave a Comment

In keeping with the fourfold goals of: improving quality of care,  identifying factors leading to readmission, preventing unnecessary readmissions and improving patient satisfaction, the University of Virginia is piloting a program in partnership with Charlottesville Pointe (a skilled nursing facility).

Known as the Transitional Care Unit or TCU program, Vishal Jain, a physician on the vanguard of this program notes:

“Our team includes a Hospitalist and a Nurse Practitioner who see the patients when they are admitted to Charlottesville Pointe. The team gets notified a day or two prior to the discharge from the hospital and then gets notified again once the patient arrives at Charlottesville Pointe. Provider team (MD/NP) round 3 times/week, spending about 1-2 hours each visit. Greater attention is paid to the discharge diagnoses, medications (and need for reconciliation thereof), Durable Medical Equipment (DME) needs, follow up testing and appointments with the specialists. All the care elements are coordinated with the primary attending of record in the facility. The expected length of stay for a patient in the TCU is about 4-6 days. We are attempting to develop a robust ancillary testing such as 4 hours turn-around time, 24 hours per day, 7 days per week for lab and imaging studies. As the program gets stronger, we would expect the facility to stock larger supply of emergency medications, including some IV meds, antibiotics, pain meds, and also have 24 hour/day capacity to administer the medications.  Overall, the goal is to provide a rigorous inter-disciplinary care to the patient in the most vulnerable period- transition from acute care to a post-acute care facility.”

Dr. Jain notes: “We are all very excited about the transitional care program.  Health reform measures are leading hospitals to focus more and more on the space beyond the physical hospital facility into post-acute and preventive areas. Several studies suggest that nearly 1 in 4 Medicare beneficiaries are readmitted to the hospital within 30 days of discharge (and the number is higher for patients diagnosed with Congestive Heart Failure).  This is not only financially discouraging but also takes a huge toll on patient’s condition and satisfaction with the healthcare system. For SNFs and other post-acute care facilities, there’s a growing recognition that they need help in managing the increasingly complex patients coming through their doors. Partnering with post-acute care providers to ensure patients continue to recover post-discharge presents a significant opportunity to improve patients’ health and reduce readmissions.”

Beyond offering more seamless transitions, this new group of practitioners also provides personalized care and a sense of continuity. This can be very reassuring for our patients and those who are caring for them.

So, welcome the transitionalists!


Filed Under: Continuum of Care, Service Line



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