Inpatient Rehabilitation: Medical Complexity: Finding the Sweet Spot-Inpatient Rehabilitation: Medical Complexity: Finding the Sweet Spot

Video Transcription

Video Summary

The video discusses the importance of transition of care for medically complex patients, focusing on moving from one healthcare setting to another. The goal is to ensure coordination and continuity of care. Outcome measures, such as readmission rates, patient satisfaction, care coordination, and functional outcomes, can assess the quality of transition of care. The video also provides tips on preparing medically complex patients for a smooth transition home, including involving patients and families in discharge planning, clear communication between providers, personalized care plans, ongoing support and follow-up, and access to community resources.<br /><br />In addition, the video addresses the question of transferring complex medical patients from inpatient rehab to a skilled nursing facility (SNF). The panel agrees that each patient should be assessed individually, taking into account their needs and potential for improvement. In some cases, it may be beneficial for patients to receive inpatient rehab before transitioning to a SNF. However, considerations such as payer sources and challenges with SNF placements should be taken into account to ensure the best level of care for each patient.<br /><br />Emergency preparedness for medically complex patients is also discussed, including registering for medically essential services, purchasing generators or portable power stations, and considering registration for medical shelters or evacuation assistance in case of emergencies or natural disasters.<br /><br />The video concludes with reminders about upcoming events, such as a geriatric member community event on post-acute care for older adults and a session on rehab considerations for patients with advanced heart failure at the annual assembly in Baltimore. No specific credits are mentioned in the summary.

Keywords

transition of care

medically complex patients

healthcare setting

coordination of care

outcome measures

readmission rates

patient satisfaction

discharge planning

clear communication

inpatient rehab

skilled nursing facility

emergency preparedness

geriatric member community event