Sharing our experience in the establishment of a Transitional Living Unit within an acute inpatient rehabilitation ward

Introduction

Discharge planning refers to ‘the development of a personalised plan for each patient who is leaving hospital, with the aim of containing costs and improving patient outcomes’, and is a common feature within many healthcare systems. ¹ A transitional living programme (TLP) may be included as part of the discharge planning process. The concept of a TLP is not new and has been described as a stay-in residential programme that is a continuum of post-acute rehabilitation since at least 1978, particularly in the traumatic brain injury setting. ² The programme length of stay (LOS) usually lasts at least several weeks. Although it is not uncommon to have a simulated home environment for rehabilitation training in healthcare facilities locally, none of them offers overnight admissions.

With an increasing fast paced healthcare environment with ever decreasing LOS, it is difficult to integrate the conventional transitional living programme within an acute healthcare setting. In this article, we aim to share our experience in the establishment and subsequent running of the inpatient stay-in Transitional Living Unit (TLU), which shares the same roots as a conventional transitional living programme with a novel operational paradigm. The TLU became operational at our institution in 2015. This innovation in care is a Singapore first, and seeks to meet a critical need in Singapore due to its ageing population and the increase in number of elderly persons living alone or with ageing caregivers.

Results and discussion

The concept of TLU arose prior to the building of the new rehabilitation ward. Patients often return to an empty home, as either their children work or they live alone. Patients and family had reservations about the patient’s ability to cope at home and that was a barrier to discharge. The idea was to increase the confidence level of the patient as well as provide a living laboratory to test out the patient’s ability to cope safely just prior to discharge.

The TLU is sited within a purpose-built acute rehabilitation ward of a regional general hospital. The design of the TLU seeks to simulate the layout of a public flat built by the Housing Development Board. It consists of two separate units. The smaller unit simulates a studio apartment and the larger unit simulates a three-room flat. Both units are designed to be elderly friendly to enhance mobility and safety for the patients. En suite bathroom/toilets are fitted with grab bars and slip resistant floor tiles with no kerbs.

A multidisciplinary TLU workgroup consisting of rehabilitation medicine physicians, occupational therapists and rehabilitation nurses was formed to establish admission criteria, rehabilitation protocols and emergency scenario planning to ensure that the TLU is utilised appropriately. The philosophy of care is to move clearly beyond a biomedical model with an emphasis on functional abilities and safety. The goal is to maximise patients’ independence and increase their confidence for independent living before discharge, without compromising patients’ safety.

The TLUs were equipped with basic household appliances and other kitchen necessities found in a typical household, based on consensus of the team. Hospital beds were installed in favour of conventional beds as, first, they facilitate the resuscitation process should the need arise and, second, dependent patients may need a hospital bed to facilitate the training of caregivers.

Closed circuit TV was not installed in view of patients’ privacy. Patients’ safety remains paramount. Although a number of emergency call bells are installed within the transitional living unit, there remains a concern that the call bell may not be within reach when required. All patients are thus required to wear a personal alarm around the wrist. The alarm can be activated by the patient manually should the need arise, such as in a fall.

The TLUs have piped medial oxygen supply with easy access to the resuscitation cart and portable ventilator located within the ward. Full resuscitation may be carried out within the TLU.

Patients who are living alone or alone for the most part of the day are considered for admission to the TLU. The admission criteria include medical stability and have a Functional Independence Measure (FIM) score of 5 across all domains to qualify for admission. The FIM score criteria are set based on consensus of the workgroup. However, the medical team may exercise discretion, such as, a patient who scores 4 for expression due to dysarthria may still be considered for admission as long as it does not pose a significant safety concern.

The FIM instrument is an 18-item ordinal scale that measures function across motor, self-care and cognitive domains. ³ The items are scored on a seven-point scale with 1 representing total dependence, 5 representing supervision and 7 representing complete independence. Patients with stable mental health conditions such as depression can be admitted. An exception exists for dependent patients requiring the care of a caregiver. This is to provide caregivers with an opportunity to simulate the caregiving roles at home. Exclusion criteria include patients with suicidal ideations, history of substance/alcohol abuse and patients on respiratory/droplet precautions. If patients fulfil the admission criteria, a quick discussion amongst members of the multidisciplinary rehabilitation team ensues so that any concerns are addressed before the patient is transferred. The team will explain to the patient and/or family members the rationale of transferring the patient to the TLU. The patient will be transferred only if they are willing to participate fully in the programme. In view of the inherent risks (mainly falls due to remote supervision) within the programme, informed written consent is obtained from the patients.

The maximum stay at the TLU is three days and two nights. The stay is managed by a core team consisting of rehabilitation nurses and occupational therapists, supported by the rest of the multidisciplinary rehabilitation team. Apart from participating in the conventional rehabilitation programme, such as group and individual therapy sessions, patients are expected to participate in activities designed by the team in collaboration with the patient. These activities are individualised to cater for the unique needs of each patient. Each patient is provided with an activity roster and the patient will have to perform the activities as listed on the roster. These activities may include making beds, cleaning the TLU, managing laundry, purchase of groceries, simple meal preparation and so on as appropriate. Although some of these activities within the TLU are not supervised, patients will be accompanied on all community-based activities beyond the hospital campus. Team members will check on the patient’s progress periodically to ensure that patients are managing. While in the TLU, nurses will check the clinical parameters of the patient twice. Blood glucose monitoring will be performed by the patient if indicated. A medication self-administration programme is available for selected patients, otherwise medications will be administered by the nurses as usual.

Both formal and informal assessments occur concurrently within the TLU. Informal assessments are observation based, conducted mainly by nurses and occupational therapists while the patient is operating within the simulated environment and the community. Some of these observations are discreetly done periodically. The FIM is used as a formal assessment at the end of the stay and progress will be discussed with the patient and/or family. The patient may proceed with discharge if the goals are achieved with no adverse events encountered. The patient may be referred for a further outpatient-based therapy programme or community support when indicated.

Apart from overnight admissions, the TLU is also utilised by the occupational therapists for daytime activities of daily living (ADL) practice. These sessions are under the direct supervision of the therapists and patients are not left alone.

As of January 2019, there was a total of 542 patient episodes, which consisted of 103 overnight admissions and 439 daytime ADL practice sessions. There is no record of a patient being admitted for the purpose of caregiver training. All patients who had undergone overnight admissions were discharged successfully. None of the patients deteriorated clinically to require a transfer to a higher acuity of care. There were no records of other adverse events such as falls.

There are several limitations of the TLU. First, the short LOS limits the breadth of activities that patients may undertake. Second, although the TLU simulates a typical public flat in Singapore, we recognise that it does not reflect the actual environmental challenges that a patient will face upon discharge. Third, there is no emphasis on vocational therapy but this is usually undertaken on an outpatient basis, should return to work be a goal of the patient.

In conclusion, the stay-in TLU is a novel concept locally. Our overall experience has been positive. It is safe and enhances a patient’s confidence prior to discharge. We recommend that such a programme be offered within all inpatient rehabilitation units.