What Is Transitional Care?

What Is Transitional Care?

Harney District Hospital and Allevant Solutions Developing Transitional Care Program

At some point, many of us have to spend time in the hospital for an illness or surgery. While you can get many of your health care needs met locally, there are services that you can only get in a larger city, like Bend or Boise. What if you have made progress in the large hospital, but still need some additional time for physical or speech therapy “rehab”, under the watchful eye of a full hospital-based care team? What if you have other medical conditions that have made your full recovery more challenging? Wouldn’t it be great if you could stay for a short time in a place close to home that provides high quality therapy services, industry-leading nurse staffing ratios, an on-site physician, and full hospital support? The good news is, now you can!

Harney District Hospital (HDH) is pleased to announce the establishment of an enhanced Transitional Care program. We asked Elaine Wulff, Chief Nursing Officer at HDH and Dan Grigg, CEO at HDH, some questions about the program.

Thanks for spending some time with us today Elaine and Dan! What exactly is “Transitional Care”?

Wulff: “Transitional Care is a high quality, evidence-based program for patients who are well enough to leave a traditional hospital setting but still have nursing, therapy, or respiratory needs that may not be optimally met in their homes or many skilled nursing facilities. Some examples of these needs would include frequent intravenous medications, wound care, breathing treatments, or intensive physical or speech therapy.”

What makes the program different?

Grigg: “HDH has partnered with Allevant Solutions, a joint venture of Mayo Clinic and Select Medical, to develop our Transitional Care program. It is modeled on the Mayo Clinic’s successful efforts in Wisconsin and Minnesota, and supported by a team that includes a Mayo Clinic pulmonologist. The program is designed to provide access to high quality post-acute services in familiar, friendly rural hospitals. As a rural hospital, we offer many supportive services that other post-acute settings cannot, such as an on-site physician, respiratory therapy, lab and radiology, and excellent nurse to patient ratios. These factors make us the best option for patients who have complex needs, multiple conditions, or other factors that make their recovery more challenging.”

How have you been preparing?

Wulff: “Our team at HDH has been implementing new evidence-based processes and completing additional specialized clinical education. We have been working on this model along with sixteen other rural hospitals across Oregon. We are also opening up new channels of communication with the larger hospitals in our region to ensure our local patients, and the larger hospitals, are aware of this option at HDH.”

Who can use the Transitional Care Program?

Wulff: “Most patients receiving this care at HDH will be covered by the Medicare Swing Bed reimbursement program, although other insurers may participate as well. In general, patients need to have a qualifying hospital stay before being admitted for Transitional Care, and have a need for skilled nursing or therapy services.”

Why is HDH developing this program?

Grigg: “As the nation’s population ages, there will be an increasing need for facilities with the expertise and capability to care for patients with medically complex conditions. Our community is no different. By enhancing our ability to provide this care, we are not only improving the post-acute care needs of our current patients, but also proactively preparing for the future.”

Will this program affect HDH’s ability to take care of regular hospital patients?

Grigg: “No. We can determine how many Transitional Care patients to admit at any given time, and still maintain capacity to take care of the day-to-day needs of our acute patients. We also have regular discussions on staffing to make sure we have sufficient staff to take care of our Transitional Care patients and our acute patients. This allows us to take full advantage of the capacity of our facility and staff. This is a win for our patients, our employees, and our community.”

What do you want readers to take away from this conversation?

Wulff: “I want them to know that HDH offers a high-quality post-acute option, right here in Harney County, and that we’d love to take care of them if they have post-acute needs!”

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