Extending a rehabilitation pathway to include multiple providers: outcomes and pitfalls

Area of Science:

• Healthcare Management
• Rehabilitation Nursing
• Patient Care Coordination

Background:

• Fragmented care across acute and subacute settings leads to poor patient outcomes and satisfaction.
• Lack of consistent caregiver support leaves patients feeling abandoned during rehabilitation.
• Challenges in managing continuity of care, cost, and accountability across the rehabilitation continuum.

Purpose of the Study:

• To address the problems of fragmented care and patient dissatisfaction in rehabilitation.
• To implement and evaluate the role of a rehabilitation liaison nurse.
• To improve continuity of care and patient support throughout the rehabilitation process.

Main Methods:

• A rehabilitation liaison nurse followed patients from acute to subacute care settings.
• Established a mutually beneficial partnership between healthcare facilities.
• Described the development of an extended care pathway and its clinical implications.

Main Results:

• Improved continuity of care for patients transitioning between settings.
• Enhanced collaboration among transdisciplinary teams and shared resources.
• Significantly decreased subacute length of stays and increased patient support.
• Patients reported a greater sense of support throughout the continuum of care.

Conclusions:

• The rehabilitation liaison nurse model effectively improves care coordination and patient experience.
• This role fosters inter-facility partnerships and optimizes resource utilization.
• Implementing a liaison nurse is crucial for seamless rehabilitation and positive patient outcomes.