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Care Coordination at Inpatient Rehab

Kami Alexander
Western Washington University

Care Coordination at Inpatient Rehab

The patient population of focus at inpatient rehabilitation at PeaceHealth St. Joseph
Medical Center (PHSJMC) are primarily patients recovering from stroke, traumatic brain injury
or spinal cord injuries. The specific diagnosis doesnt necessarily qualify a patient for inpatient
rehab as much as the patients ability to progress towards their baseline functioning and
participate in at least three hours of therapy per day. Patients in the rehab program can be of any
age over 13.
Care Coordination Model:
At inpatient rehab, they are not currently using a particular care coordination model.
However, their care coordination strategies are similar to the Naylor model, a transitional care
model designed by Mary Naylor and a team of experts at the University of Pennsylvania. This
would be an effective model because it utilizes a multidisciplinary approach to transitional care
very similar to the strategies already utilized at inpatient rehab. The Naylor model is effective in
assisting adults with the transition from hospital to a lower level of care. This model allows care
coordinators to follow patients for approximately 12 weeks post discharge to ensure they have
everything they need to be successful. Hospital readmission rates decrease significantly when
this model is utilized.

Literature Review
According to Volland, Schrader, Shelton and Hess (2013), transitional care coordination
models reduce healthcare costs for adults with chronic illnesses by utilizing a team to manage
every aspect of patient care. The goal of transitional care coordination is to adequately prepare
patients to be successful at a lower level of care. In the inpatient rehab program many patients
have suffered from an acute injury such as a stroke, traumatic brain injury or spinal cord injury.
A transitional care coordination model is successful because when patients successfully complete
the program they are often close to their baseline and only need short term follow up. This relates
to the Naylor transitional care model by focusing on reducing communication gaps and hospital
readmissions due to chronic illnesses.
Toles, Colon-Emeric, Naylor, Barroso and Anderson found that when skilled nursing
facilities effectively utilized a transitional care model they met the goals of the patient and
caregiver more frequently than facilities that did not. It was also found that transitional care
services are associated with reductions in 30 day hospital readmissions of skilled nursing facility
patients (Toles, Colon-Emeric, Naylor, Barroso and Anderson, 2016).
Care Map
This care map (please see Appendix A) describes a patient who was a marathon runner.
He was running a 92 mile marathon and began to feel short of breath and dizzy after running 30
hours. He was brought to the hospital and found to be in acute renal failure. During this
hospitalization he developed confusion and became deconditioned. He was discharged to a
skilled nursing facility for rehabilitation. While at the skilled nursing facility he developed

endocarditis which affected his mitral valve and caused severe regurgitation. The patient then
suffered a stroke and was re-hospitalized. While hospitalized, the patient underwent a mitral
valve replacement and was eventually admitted to inpatient rehab. While in the inpatient rehab
program he underwent intensive physical, occupational and recreational therapy with
approximately a 50 percent improvement in overall functioning.
While admitted to inpatient rehabilitation this patient is participating in physical,
occupational, recreational and speech therapy for 3 hours each day. Additionally, several
specialists are following his case. I also included the patients family supports in the care map.
Upon discharge the patient will likely need additional therapy, either inpatient or outpatient.
This patient is likely to be successful because he has a large support system including a
very helpful family and supportive friends who are strong advocates. Insurance will cover the
majority of his medical expenses and his family has the monetary means to provide anything that
may not be covered. He was also exceptionally healthy before these events. The care
coordinators are working hard to ensure the patient and family have all of the necessary
equipment and information for discharge.
Unfortunately, this patient is at high risk for readmission within 30 days because he is
still cognitively impaired and is at high risk for re-injury. He will likely need 24/7 supervision
upon discharge. He is a high fall risk due to his memory loss and impulsiveness. Both of these

factors are common reasons for readmission. It will be important to follow up with outpatient
therapy to continue the healing process and avoid any further injuries.
Plan of Care
Problem: Patient is at risk for readmission to the hospital within 30 days
Goal: Prepare patient and family with resources, equipment and education needed for
success at home to reduce the risk of readmission

Ensure the patient has 24/7 care at home for early recognition of deterioration
Set up follow up appointments with primary care provider and specialists as necessary
Provide education for all caregivers regarding medications and signs and symptoms of

Continue PT and OT for strengthening as an outpatient
Early discharge follow up to anticipate needs

Problem: Patient is at risk for injury by falling

Goal: Reduce the risk of injury by falling at home

Remove clutter and other trip hazards from the home

Provide patient with necessary equipment at home
Always ensure that patient has a clear path to the bathroom and other common areas
Keep bed in the lowest position
Provide patient with non-slip socks

If the above interventions are implemented, this patient will have a lower risk of being
readmitted to the hospital within 30 days as well as a lower risk of new injuries after falling at

home. By avoiding these risk factors this patient will be able to continue working toward his
baseline health status.
Toles, M., Coln-Emeric, C., Naylor, M. D., Barroso, J., & Anderson, R. A. Transitional care in
skilled nursing facilities: a multiple case study. (BioMed Central May 17, 2016). Retrieved from
Volland, P. J., Schraeder, C., Shelton, P., & Hess, I. (2012). The transitional care and comprehensive
care coordination debate. Generations, 36(4), 1319.