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Navigating Hospitalizations 101: Transitional Care Units

11/8/16 by Sarah Lahr

As we discussed in the first post in Navigating Hospitalizations 101, hospitals are one of the most complex systems in our nation. If you are caregiving for a family who is hospitalized, one of the challenges you may face is learning what the needs will be for the person you are caring for after leaving the hospital. In some cases, you find out only a few hours in advance that your family member is being discharged and needs placement in a Transitional Care Unit.

In this post, you will find tips for securing a Transitional Care Unit as you navigate hospitalizations. The previous post covered communications with the care team.

Anticipating the Need for a Transitional Care Unit

A Transitional Care Unit is short-term stay in a skilled nursing facility where people can receive further physical and occupational therapy. Since hospitals no longer keep patients until they are well enough to return directly home, transitional care is a very common recommendation as an extension of the hospital stay. It is a level of care where the focus is on building strength and endurance through physical and occupational therapy before the person you care for returns home.

Selecting a TCU

  • Social workers have a list of TCU facilities to choose from. However, if you are unable to speak with a social worker until day of discharge, check out the Minnesota Nursing Home Report Card or Nursing Home Compare for options of facilities that best meet your standards. It is also a good idea to tour your top three facilities and speak with other caregivers.
  • When the social worker comes around, you will then be prepared to provide them with your top three choices for them to check on availability and make referrals. NOTE: You may not get into your first or second choices. Be sure all three options are places you feel good about.

Medicare Coverage for TCU

  • Patients need to have a 3-day “inpatient” hospital stay in order for Medicare to cover transitional care. Refer to Medicare.gov for Medicare Guidelines.
  • Ask the nurse if the person you care for is under “inpatient” or “observation” status. If they are under “observation,” request a review of the patient’s chart to see if they meet “inpatient” status guidelines. If transitional care is recommended for an observation status patient, most facilities request up to one month’s payment upon admission ($3,000-$6,000). If the patient doesn’t stay for a full month, the amount they don’t use will be refunded in most cases. Make sure to work with staff at the TCU to understand billing, admissions and other costs associated with a stay. 

Signs that You, the Caregiver, May Need More Support at Home

  • Check in with your emotions while the person you are caring for is in the hospital. Are you finding that you are feeling relief by not having to provide so much physical care? If so, it may mean that you need more support in your caregiving role. (Although you may be relieved of providing physical cares, a hospitalization or transitional care stay is not necessarily respite for caregivers…your caregiving tasks have just changed).
  • If TCU is being recommended under an observation stay, this is a major indication that more support may be needed at home. If paying privately at a TCU is not a possibility, speak with the social worker about other options. Wilder’s Caregiver Services Team is a great resource to talk through options for more support as well.

Selecting a transitional care unit can feel overwhelming, but with a little support, you can help ensure that the needs of you and the person you are caring for are met.

Sarah Lahr spent the summer 2016 working full-time as a medical hospital social worker. She previously worked in the Wilder Foundation’s Caregiver Services Program as the care coordinator. She is starting graduate school this fall in the Masters of Public Health Administration & Policy program at the University of Minnesota to study the integration of the healthcare system and home & community-based services to support older adults and their caregivers in their communities.

Photo: G'ma's hospital bed before she got there |  dreamingofariz | Attribution 2.0 Generic (CC BY 2.0)