Transitions of Care: Navigating the Post-Acute Care Landscape, Part 2

This month we speak with a case manager.

What are some of the admission criteria in place for patients to be admitted to SSH?

A good portion of our patients need to have been treated for a critical illness that required ICU-level care for at least three midnights. We provide a wide range of medical care at SSH—from people who are just requiring two to three weeks of IV antibiotics to people who require dialysis and respiratory support with a ventilator. The average length of stay at our facility is three weeks, but we have had people stay ranging from a couple of days to six months.

Oklahoma is a large state. How many facilities like yours do we currently have?

We have three LTACHs in the Oklahoma City metro along with a few more in Tulsa and some areas of the state. All in all, we probably have around half a dozen LTACHs.

Where do patients tend to go once they are discharged from SSH?

We want to send everyone home, but we have to make sure it is a safe discharge. One way to assess that is to think through different scenarios our patients would be facing at home. Would they be able to get out of the house if they encountered a house fire? Would they be able to perform their own wound care or have a loved one assist with that? If the answer is no to those, we start looking at skilled nursing facilities or inpatient rehab centers.

What is the difference between a skilled nursing facility (SNF) and a nursing home?

SNFs require patients to participate in physical activities as part of the treatment plan. They also provide skilled care such as intravenous antibiotics and oxygen therapy. Nursing homes do not provide these services but instead act as a home. SNFs are temporary destinations.

What are some of the more difficult discharges you or your peers had to work on?

In the state of Oklahoma there are no long-term care facilities that provide dialysis along with respiratory support. We have had to send people to Georgia, Illinois, and New York. We don’t like to do these discharges that end up separating our patients from their loved ones.

Is there something you wish families knew about your facility or about navigating the post-acute care landscape?

It’s important to keep in mind that patients at an LTACH are still critically ill and require a lot of medical care and support. Patients in swing bed units, SNFs, or inpatient rehabilitation facilities are typically physically able to do more than a good portion of our patients. We will always do what is best for the patient even if it means taking a break from physical, occupational, or speech therapy on any given day to focus on medical needs.

For more information, be sure to read Part 1 of this article, which ran in the June 2021 edition of Oklahoma Living.

Dr. Gabriel Vidal is a board-certified internist who is currently pursuing further training in oncology at the Stephenson Cancer Center at University of Oklahoma Health Sciences Center.