Kindred Hospital Seattle – First Hill has begun using Swedish’s TeleICU system to provide an additional layer of care and clinical monitoring for its patients.
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Just as there are different kinds of patients, there are different kinds of hospitals. Kindred Transitional Care Hospitals provide a wide range of services to help patients with complex medical issues who need additional recovery time after a stay at a traditional hospital. While every patient receives individualized care from a team of healthcare professionals, our goal is for each person to reach the highest level of recovery before discharge.

With our Direct Admit Program, physicians can admit medically complex patients from short-term acute care hospitals, skilled nursing facilities, home health and other service providers directly to a Kindred Hospital. We work directly with physicians to make sure their patients have a smooth transition into our hospitals and the highest level of care continuity to prevent future readmissions.

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When someone suffers a traumatic brain trauma — whether it’s from an automobile accident, severe stroke or other injury — he or she is initially admitted to an Intensive Care Unit. After patients are medically stable, it may be necessary to transfer them to a long-term acute care or transitional care facility before an acute rehabilitation or subacute rehabilitation facility.

According to Terry Eberly, a speech pathologist at Kindred Hospital Denver, two assessment methods are used to determine the extent of the injury and issues that need to be addressed:

Based on the results of the evaluation, a plan is customized to the needs of the individual, encompassing and integrating therapies to treat respiratory, speech, motor, visual, orthopedic and other identified issues.

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Kindred’s Transitional Care Hospitals play a vital role in the recovery process for the sickest and most medically complex patients who require aggressive medical care and rehabilitation over a longer period of time. For patients who have complex ventilator needs, multi-organ system failure or complicated medical problems that are very difficult to treat, transitional care hospitals may represent the first important step necessary to make recovery and return home possible.

These hospitals are licensed as general acute hospitals, often featuring such familiar elements as Intensive Care Units (ICUs), operating rooms and on-site laboratory and radiology services, but they also are distinguished by an additional Medicare certification that recognizes the need for extended recovery periods.

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Transitional Care Hospitals (TCHs) offer aggressive, medically complex care, intensive care and short-term rehabilitation.

Certified as long-term acute care hospitals and licensed as acute care hospitals, Transitional Care Hospitals are unique in their ability to care for critically ill patients who require specialized and goal-directed care over an extended recovery time. They have an additional Medicare certification that supports a length of stay measured in weeks as compared to the typical five-day stay for patients in traditional hospitals. At Kindred, about two-thirds of our TCH patients have Medicare.

TCH patients require an average length of stay of 25-30 days, and have many co-existing medical conditions, some acute and some chronic. Examples of some of the services TCH patients require are:

Some of the conditions commonly seen in a TCH are:

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A brain injury can happen anytime, anywhere and to anyone — and result in a lifetime of physical, cognitive and behavioral challenges. In fact, 1.7 million people (including 475,000 children) sustain a traumatic brain injury every year.

March is Brain Injury Awareness Month, but Dale Richard Mulder, CEO at Kindred Rehabilitation Hospital Clear Lake in Webster, Texas, is aware of these injuries all year long. He says, “Every brain injury is different. As such, we tailor therapy to suit the needs of the individual. Our physical, speech and occupational therapists work to retrain the brain and provide adaptive techniques and devices so the patient can regain independence.”

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With February being Heart Month, and knowing that heart disease is one of the readmission penalty diagnoses, I paid attention when I recently read a study in Annals of Internal Medicine from investigator Janet Prvu Bettger and collaborators from Duke and Wake Forest.[i] This study looked at the role of transitional care interventions in patients who had recently suffered a heart attack or stroke. The question was legitimate:  what interventions around transitions work to improve outcomes? What they found was sobering.

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For Polly Moore, MD, FACC, helping patients live and die well with heart failure is not just a job, it’s a passion. One that started 25 years ago when she began her career as a nurse and found satisfaction working with heart patients in the emergency room.

Dr. Moore, now a cardiologist with Franciscan Physician Network Indiana Heart Physicians, is director of the practice’s Heart Failure Care Clinic and works with Kindred as a consultant, rounding on cardiac patients at Kindred Hospital – Indianapolis South, and providing clinician education there on the heart disease process.

“I was drawn in particular to the heart failure patients, primarily because of the way heart failure impacts their whole lives,” she said. “I try to teach the patients and their families how to get the heart failure under control so they can live well with it.”

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In honor of National Cardiac Rehabilitation Week, we are highlighting a unique monitoring system that ensures that any change in a patient’s condition triggers the appropriate medical response.

Because the care of a cardiovascular patient can be extremely complex, Pamela Zanes, District Director of Clinical Operations, recently implemented simple-to-use, but very effective, systems for monitoring the condition of each patient. Congestive Heart Failure Zone management uses information about breathing, swelling, weight gain, chest pain, and activity level to determine when a physician should be called. The Stop and Watch Early Warning Tool encourages anyone in the room to observe and report changes in patient behavior.

“Someone might notice something different, such as the patient is less talkative than the day before or a sudden weight gain that might be a sign of edema. Heart failure is a long-term condition with symptoms that can begin suddenly,” Zanes says.

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Once again, Dr. Joe Ouslander  points the way to a greater understanding of the complexity of hospital readmissions from Long-Term Care settings.  Because Long Term Care (LTC) comprises a distinct set of services, settings, interdisciplinary team members, and trade-off’s between benefits and burdens of a given decision to hospitalize, the measures currently used for hospital readmission payments or penalties fall short.

 

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