Abstract
Post-acute care (PAC) facilities improve patient recovery, as measured by activities of daily living, rehabilitation, hospital readmission, and survival rates. Seamless transitions between discharge and PAC settings continue to be challenges that hamper patient outcomes, specifically problems with effective communication and coordination between hospitals and PAC facilities at patient discharge, patient adherence and access to cardiac rehabilitation (CR) services, caregiver burden, and the financial impact of care. The objective of this review is to examine existing models of cardiac transitional care, identify major challenges and social factors that affect PAC, and analyze the impact of current transitional care efforts and strategies implemented to improve health outcomes in this patient population. We intend to discuss successful methods to address the following aspects: hospital-PAC linkages, improved discharge planning, caregiver burden, and CR access and utilization through patient-centered programs. Regular home visits by healthcare providers result in decreased hospital readmission rates for patients utilizing home healthcare while improved hospital-PAC linkages reduced hospital readmissions by 25%. We conclude that widespread adoption of improvements in transitional care will play a key role in patient recovery and decrease hospital readmission, morbidity, and mortality.
Highlights
The rapid growth of the geriatric population will trigger a necessary increase in utilization of healthcare resources, including the use of surgical specialties such as cardiac surgery; transition of care following cardiac surgery will continue to increase in importance in the coming years [1]
The post-acute care (PAC) options covered by this review include skilled nursing facilities (SNFs), long-term acute care hospitals (LTACHs), cardiac rehabilitation (CR) centers, and the patient’s home
Seamless transition of care is becoming increasingly important for high-risk patients, undergoing major cardiovascular-related surgeries since the rates of Cardiovascular disease (CVD) are rising in the United States’ aging population
Summary
The rapid growth of the geriatric population will trigger a necessary increase in utilization of healthcare resources, including the use of surgical specialties such as cardiac surgery; transition of care following cardiac surgery will continue to increase in importance in the coming years [1]. Transition of care is defined by The American Geriatrics Society as the “set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. It includes the logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition” [2]. The post-acute care (PAC) options covered by this review include skilled nursing facilities (SNFs), long-term acute care hospitals (LTACHs), cardiac rehabilitation (CR) centers, and the patient’s home
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