Transitional care, progressive mobility help patients with post-acute care recovery

The article, "Progressive Mobility as a Team Effort in Transitional Care," reviews post-acute transitional care as provided at a skilled nursing facility in western New York and examines the individual roles of various interdisciplinary team members, including progressive care nurses.

Patients recently discharged from the hospital may move to a transitional care facility as they strive to regain their functional abilities and independence. Their diverse conditions may include congestive heart failure, chronic obstructive pulmonary disease, pneumonia and postoperative debility, all requiring skilled nursing and rehabilitation.

"With the increased focus on reducing readmissions, it has become imperative for all members of the interprofessional team to coordinate plans of care for each patient in transitional care," said lead author Margaret Ecklund, RN, MS, CCRN, ACNP-BC.

Ecklund is a lead advanced practice nurse for the complex care transitional program in the Rochester General Health System, New York.

In the article, she discusses the importance of interdisciplinary team strategies for incorporating progressive mobility and functional independence into the daily routines of transitional care patients.

Mobility is a core component of patients' care plans and a crucial element of their being discharged home. It is also a key indicator for insurance coverage for post-acute stay at a transitional care facility.

"Mobility gets woven into the fabric of daily activity, rounds and plan of care," Ecklund said. "In a culture of progressive mobility, team members hold one another accountable for their roles in safe mobility."

Transitional facilities are among the growing number of healthcare environments where progressive care nurses care for high acuity patients who are not in intensive care but require highly skilled nursing.

The journal article adds to the body of knowledge related to progressive care nursing, which is the unifying term for the increased level of care and nursing vigilance needed by patients who have complex healthcare needs but are not critically ill.

The American Association of Critical-Care Nurses (AACN) introduced the term progressive care more than a decade ago to describe the care needs of acutely ill patients who are moderately stable with a high risk of instability.

Other common terms for progressive care settings include stepdown, intermediate, telemetry, transitional, high acuity, direct observation or medical-surgical progressive care units. Progressive care nurses also may practice in long-term acute care hospitals, where patients -- especially those who are ventilator-dependent -- may receive care.