Acute Discharge: Levels of Care, Education, and Transition Planning

Transitional care includes a broad range of services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one setting to another. Representative locations include hospitals, long-term acute care hospitals (LTACHs), skilled nursing facilities (SNFs), acute inpatient rehabilitation facilities (IRFs), the patient’s home, primary and specialty care offices, and long-term care facilities. Poor transitions between acute inpatient and post-acute care can lead to adverse events, unmet needs, low satisfaction with care, and high rehospitalization rates for patients with traumatic brain injury and spinal cord injury. An acute hospital interdisciplinary treatment team led by neurorehabilitation consultants can determine the appropriate level of rehabilitation care after acute hospitalization and facilitate a safe transfer to post-acute care.