Transitional Care Programs

Transitional Care

The objective of our Transitional Care strategy is to develop and implement effective and innovative programs designed to provide patient care outside of the hospital and in more comfortable care settings, such as a patient’s own home. We call this the “Care Continuum.” These evidenced-based innovations are grouped into two broad categories: Home Based Care and Post-Acute Care.

Home Sweet Home

Home Based Care, or care provided in the home, can take the place of an actual hospital admission (Home Hospital), prevent an emergency room or urgent care visit (Partners Mobile Observation Unit) or help patients self-manage their Congestive Heart Failure at home (CHF Telemonitoring).

Post-Discharge: Where Do We Go From Here?

Acute care is care that is provided in the hospital setting, while Post-Acute Care services can be leveraged after the acute stay has been completed, if the patient requires continued care that can be managed in a less acute setting. Some Post-Acute Care settings provide complex care that is less intensive than the hospital, including:

  • Long Term Acute Care (LTAC) – for patients who still require medically complex care
  • Inpatient Rehabilitation Facility (IRF) – for  patients in need of intensive physical rehabilitation and complex care post-hospitalization
  • Skilled Nursing Facility (SNF) –  for a less intense care setting

Partners Population Health post-acute work focuses on Skilled Nursing Facilities. If the appropriate criteria are met, patients can move directly from the hospital or home to a Skilled Nursing Facility, or can transition from a Long-Term Care Facility to the Skilled Nursing Facility for continued care. These programs are delivered along the “continuum” of patients’ ever changing care needs and can be layered to provide patients with an individualized and comprehensive plan to provide the very best care.

For example, a Congestive Heart Failure (CHF) Telemonitoring nurse may determine with the patient that there is an urgent care issue and will call the Primary Care Provider for a referral to have an Urgent Care Nurse Practitioner (NP) see the patient at their home. If appropriate, that nurse could facilitate a short stay at a Skilled Nursing Facility to get the patient’s care back on track and help the patient return home as quickly as possible.

Making A Difficult Journey Easier

End-of-life care, often referred to as Palliative Care, is the term used to describe the support and medical care given during the time surrounding death. Such care is not limited to the moments before breathing ceases and the heart stops beating; people with serious illnesses like cancer, COPD, ALS, or other advanced, chronic illnesses often need more specialized care for weeks, months, or even years before death.

This type of care is focused on providing relief from the symptoms and stress of a serious illness, and improving quality of life for both the patient and their family during this difficult journey. At hospitals and clinics across the Partners system, clinicians are piloting new ways of supporting patients through end-of-life transitions. Learn more about our end-of-life care programs.

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