Transitional Rehabilitation for Cardiac Patients

UPMC has been at the forefront of the transitional rehabilitation wave. For patients requiring intensive but short-duration (typically two weeks or less) rehabilitation after a hospital discharge, but who are not able to transition directly home or who need the advanced services of a long-term care facility, the advent of TRUs is bridging the gap.

The number of these Transitional Rehabilitation Units (TRUs) has steadily grown over the last five years, with TRUs in operation at most of the skilled nursing and rehabilitation facilities within the UPMC Senior Communities network.

In October 2016, the first cardiac-specific TRU began accepting patients at Canterbury Place. Shuja Hassan, MD, medical director of Canterbury Place and assistant professor in the Division of Geriatric Medicine, helped to spearhead this new initiative with colleagues from the UPMC Heart and Vascular Institute (HVI) and the UPMC Rehabilitation Institute. The HVI-TRU is a 17-bed unit that was remodeled prior to opening and consists entirely of private rooms for patients. "Our patient population typically consists of individuals with complex heart failure, those who have had MIs or catheterization procedures, valve replacement surgeries - TAVRs - and individuals with cardiomyopathy. However, we can handle the care and rehabilitation of just about any cardiac patient, be it medical or surgical, regardless of age," says Dr. Hassan.

Collaborative, Multidisciplinary Care

As the medical director of Canterbury Place, Dr. Hassan oversees the care of most of the HVI patients who make their way to the unit, and he collaborates closely with several individuals from the UPMC HVI on patient care. Patient rounds are conducted every Thursday and typically include Dr. Hassan and nurse practitioners assigned to the unit, Lauren Dornin, CRNP, and Jill Braver, CRNP. Joining them are clinicians from the HVI, Michael Mathier, MD, and Ravi Ramani, MD, in addition to, Jennifer Kliner, CRNP, MSN, ACNP-BC. "We collectively discuss the new admissions, their care plans, and the continuing care of patients on the unit. The collaboration between geriatrics, cardiology, and rehabilitation really affords our patients the best quality of care possible, and a high degree of continuity of care not only between everyone at Canterbury Place, but at the hospital prior to their admission to the unit," says Dr. Hassan.

The HVI-TRU at Canterbury Place generally runs at full capacity, pointing to the need for this kind of care and what is sure to be a growing patient population as individuals are living longer with chronic cardiac conditions, and more and more individuals undergo such interventions as valve replacements at increasing years of age.

A Continuing Evolution

Even though the HVI-TRU has only been operational for a little more than a year, Dr. Hassan and his colleagues have worked to adapt the administration of care to better align with the patient population and their needs. "Several months ago, we instituted a process whereby physician assistant and nurse practitioner members from the HVI cardiothoracic surgery team at UPMC Shadyside now visit the unit three days a week to see, and discuss with me, the care of postsurgical patients. Again, this leads to better coordinated care for the patient through enhanced communications and planning," says Dr. Hassan.

Furthermore, plans are in place at Canterbury Place to outfit a dedicated floor purely for long-term heart and vascular residents. "The nature of our patient population is always evolving. So too is the broader world of health care. It is incumbent upon us as providers and institutions to evolve to meet these changing needs, and to meet and exceed the benchmarks of care that we hold for ourselves and our patients," says Dr. Hassan.