Transitional Care Units: An Overview for Nurses

• Nurses must understand the purpose of transitional care units to assist patients in necessary recovery and rehabilitation. 
• Understanding the benefits and advantages of transitional care units is essential.  
• A transitional nurse has many roles and responsibilities, and these must be understood, along with how to become one if one desires to do so.  

When a patient leaves the hospital following treatment of an acute condition, they might require ongoing care for chronic medical conditions and assistance with their day-to-day routine. Their care might even require special equipment or services. In these situations, a transitional care unit provides supportive care and promotes safe and timely transition across care settings. 

The Purpose of Transitional Care Units

The transitional care unit is often a short-term care facility (less than 21 days) for medically complex patients transitioning from the hospital to home or from one care setting to another. Its purpose is to provide the nursing and rehabilitative care necessary to help patients regain a certain level of independence.   

Depending on the patient’s condition, care might include:  

• Rehabilitative restorative or skilled care  
• Physical therapy  
• Occupational therapy  
• Speech therapy  
• Hemodialysis for individuals with renal failure  
• IV therapy and frequent laboratory tests  
• Intravenous anticoagulation therapy  
• Wound care  
• Fall prevention  
• Ventilator care and respiratory therapy  
• Nutritional counseling and dietary planning  
• High flow oxygen and cold respiratory therapy monitoring  

High-quality transitional care is especially critical for older patients with complex or chronic conditions. To qualify for admission to a transitional care unit, patients must be able to participate in daily intensive rehabilitation therapy with the goal of restoring their maximum level of functioning and fitness.  

Benefits of Transitional Care Units

The primary benefit of a transitional care unit is the coordination and continuity it provides during transitions between locations or levels of care. It bridges the gap between various providers, services, and settings and ideally includes education about the next stage of recovery for the patient. Transitional care programs also significantly lower readmission rates due, in part, to a variety of comprehensive services aimed at improving the transition to home, such as:  

• Medication evaluation and optimization  
• Patient family education  
• Social services or discharge planning  
• Individual home exercise programs  
• Visiting nurse arrangements  
• Post-discharge outreach  
• Home visits  
• Primary care provider follow-up  

Advantages of Transitional Care

Unlike community-based, subacute care facilities with limited medical resuscitation equipment or the staff training to use it, transitional care units have immediate access to acute resuscitation services. Because transitional care units are hospital-based rather than community-based, their radiology and laboratory facilities are on-site. In addition, transitional care units have an onsite medical doctor 24 hours a day and access to all transitional care specialties.  

The availability of multidisciplinary care is one of the main reasons transitional care units can care for patients with multiple complex conditions. Their expansive rehabilitation services, such as physical and occupational therapy, are precious for patients recovering from orthopedic procedures.  

Suppose a patient would benefit from short-term, ongoing specialized medical services and rehabilitation following hospitalization and are not yet appropriate for discharge. In that case, a transitional care unit may be an ideal option. The continuity of care and range of services provided effectively bridge the gap between acute care and discharge. This lowers the risk for hospital readmission, reduces complications related to transfer of care, and improves patient satisfaction. Transitional care units are a mode of intermediate rehabilitative care dedicated to facilitating a safe discharge home or to another facility, enabling patients to resume a more active and fulfilling life.  

The Role of a Transitional Care Unit Nurse

A transitional care nurse oversees the patient’s care as they move from one health care facility, such as a hospital or nursing home, to another facility or their home. The transitional care nurse ensures the relocation is as smooth as possible and helps the patient remain comfortable during the change.  

Duties include creating a transitional care plan with the patient’s physician and family members to determine when and how the move should be made. Once the patient is established in the new facility or back home, the nurse visits them regularly to assess their health and recovery. The transitional care model of healthcare aims to reduce disruption and care and lower the chances of patients relapsing and returning to the hospital.  

Why should you become a transitional care unit nurse?  

Since many patients in transitional care units have complex health issues, this specialty requires a variety of nursing skills. If you enjoy frequent shift changes, transitional care nursing might be for you. Since transitional care patients are often short-stay patients, your patients are constantly changing. If you enjoy working with older people, this is another benefit of working as a transitional care unit nurse.   

How do you become a transitional care nurse?  

The primary qualifications for becoming a transitional care nurse are an associate or bachelor’s degree, a current state nursing license, and experience discharging patients in the transitional care model. Some employers prefer applicants with a master’s degree in nursing, but the most essential qualification healthcare organizations value is experience.  

Transitional care nurses often work with seniors and chronically ill older adults, so any experience with that patient population can help you stand out. Most transitional care nurses work in a hospital or other healthcare facility for several years before applying for this position.  

What is the most significant role for nurses in care transition and reducing readmissions?  

Nurses must navigate communication and coordination of patient care, and they are best equipped to coordinate a successful transition. The bedside nurse may understand the patient’s needs more as they travel through the care facilities more than any other healthcare team member. When those needs are communicated effectively, the nurse can provide high-quality nursing care to the patient.  

Nurses create transitional care plans by gathering vital patient information in the electronic health record and building instructions to be followed. Then, they collaborate and share the plan with all care team members. This ensures the handoff is seamless for the patient and the new care team. Communication during and after the handoff process is the most crucial factor in transitional care.  

The goal of the handoff is to safely transfer the patient from one care setting to another by exchanging the necessary information and effectively transferring the care responsibility to either a new care team or the patient’s family.  

The Bottom Line

Transitional care units are specialized units with the ability to provide care for patients with a wide range of medical conditions. Transitional care units improve patient outcomes by reducing complications that can occur during the transition between care settings. Complications can include medication errors, infection risk, and undertreatment of chronic conditions. Transitional care units are vital in promoting patient safety and increasing the patient’s quality of life. 

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