Feb 26, 2021 Transitional Care — Between Hospital and Home

The Transitional Care Unit offers a short stay with long-term benefits.

If a hospital patient is ready to be discharged but is not quite ready to be at home, he or she is often sent to a rehabilitation facility. Clara Maass Medical Center (CMMC) offers an alternative: the Transitional Care Unit, known as the TCU.

Located on the second floor of CMMC’s Continuing Care Building, the TCU offers multidisciplinary care for up to eight days after a hospital stay. It’s one of only five TCUs in New Jersey.

John Kelly, MD
John Kelly, MD

“Let’s say you have a patient who fell and broke a hip but doesn’t yet have the ability to ambulate and care for himself,” says John V. Kelly, MD, Medical Director of the TCU. “Our unit gives him the ability to get out of the hospital but also be in a short-term setting where his care and physical therapy can continue.”

Other examples of patients who don’t need hospital-level care but would benefit from a short-term stay include those in need of cardiac recovery, post-surgical recovery, pulmonary management, oncology and pain management, and skin and wound care. Often, a few extra days for recovery in the TCU is all that’s needed to regain strength and function and be successfully discharged to home.

“The difference between our unit and a traditional subacute skilled nursing facility is that we offer very concentrated services over the course of a short stay,” explains Jennifer Horath, LNHA, Director of the TCU. “Our goal is to get people ready for discharge to their traditional home setting in about a week.”

Calm and Comfort

Because the TCU is located at One Clara Maass Drive, next door to the main CMMC complex, it’s convenient for patients, and they can continue to see the same doctors. However, TCU has its own employees, admissions department and case manager, and an environment that’s very different from a hospital.

Because the unit can accommodate a maximum of 20 patients, personalized, focused care is the norm. “We look at every single patient’s case daily with an interdisciplinary team to make sure we’re staying on point with our goals,” Horath says. “As you can imagine, a physical therapy program looks a lot different when the PT team is dealing with 20 people rather than 250.”

The atmosphere and environment have a homier feel than a hospital. “Unlike a hospital, we don’t have a lot of signage to indicate what’s going on clinically,” says Dr. Kelly.

However, TCU personnel practice the same safety precautions as those in the hospital. “Everyone in the facility has been screened for COVID-19, wears a mask, and practices strict social distancing protocols,” Dr. Kelly explains.

The rooms have been designed for serenity, with soothing colors appropriate for healing. Patients are allowed to bring some personal belongings, such as clothes or blankets, both to make themselves more comfortable and to help them prepare for going back to their normal routine.

No matter how comfortable the TCU is, however, it is made for a short-term stay. “It’s top-notch care, but there’s a reason it’s called ‘transitional’ care,” says Dr. Kelly. “Our goal is to get you home as soon as possible.”

To learn more about the Clara Maass Medical Center Transitional Care Unit, call (973) 450-2220