Lieberman +30, Making a Difference After Rehab

by Mary Keen

Lieberman +30 Transitional Nursing Program, the only one like it in Chicago and the northern  suburbs, is offered for patients transitioning from rehabilitation to home, as an important bridge in the recovery process. With shorter stays and the greater complexity of medical needs, research has shown  that patients returning home after rehab (particularly  older individuals) may not understand how to manage their medical conditions after discharge or have the support needed for a successful recovery.

Research has also found that during transitions,  patients’ personal goals and elements of their individualized needs often were lost in the transition process. If transitions are poorly managed, both patients and caregivers can experience a great deal of physical and emotional stress.

The goal at Lieberman Center’s Haag Pavilion for Short-Term Rehabilitation has always been to help manage our patients’ successful transition from  a hospital stay to home. Because of our person-centered care and evidence-based practices, we have been able to achieve excellent outcomes with an average annual re-hospitalization rate below the national average. To help maintain these positive outcomes, and to transition patients home with  less stress and a better understanding of self-care, Lieberman Center launched the Lieberman +30 Program last November. It was designed to provide patients and their families with education about their conditions and medications and to coach them on the needs and importance of follow-up care with their community-based healthcare professionals.

Patients being discharged from the Lieberman Center are given the opportunity to participate in the program, which provides instructions, education and guidance for multiple conditions and functional needs. The program’s primary objective is to give patients and their caregivers the tools to monitor their chronic medical conditions like diabetes, COPD, kidney disease and heart failure, the major cause of re-hospitalization among the older adult.

How does it work?

The Lieberman+30 Transitional Care Program provides access to a Transitional Care Nurse (TCN) who keeps in contact with patients for 30 days after discharge and monitors their discharge plan. The Program delivers three basic services:
    

  • A personal 30-day Discharge Plan developed by staff.
  • Home Transition Assistance provided by the TCN who visits all participants in their home within 72 hours of discharge.
  • Sustained Monitoring by the TCN, who makes weekly phone calls to check up on patient progress.

Employing a coaching technique, the TCN helps patients and caregivers become comfortable in managing their own medications and health information, instructs them in understanding what signs and symptoms to watch for that would cause  them to contact a healthcare provider and helps them  build skills to ask important questions.

According to Erin Pruzenski, the Lieberman +30 Transitional Care Nurse, “Lieberman +30 provides an extra layer of support during the transition period to home. This support helps to keep patients mindful of their needs after being discharged. With so much
complex information and detailed instruction given to them upon discharge, it can be overwhelming.”  Also, evidence has shown that individuals who take an active role in managing their medical conditions at home can reduce the likelihood of re-hospitalization.

As a tool, the TCN utilizes a “stoplight” Zone Management System, in which patients are provided with easy-tounderstand instructional posters on what to do if symptoms develop. The posters graphically organize symptoms and conditions
in green, yellow and red zones, corresponding to a wellness hierarchy indicating “Doing Well,” “Warning” and “Stop,” respectively. For instance, the Yellow Zone recommends a call to a professional and the Red Zone requires a call to 911.  

“These tools and other instructions have been very effective in teaching both the patient and caregivers about the specifics of a medical condition and how to self-manage if symptoms develop,” says Pruzenski.  “The results of the program have proved promising and patients and their caregivers are responding well,” she added.

 

 

At Lieberman Center, we recognize that providing access to a dynamic continuum of health care is an important factor in quality of life issues. We not only care how our patients recover while under our roof, but we also care about how they do after they go home.

To find out how our Lieberman +30 Transitional Nursing Program helps patients manage their  medical conditions after discharge, please call  847.929.3342 for more information.  The Lieberman +30 Program is supported in part by the Braun Fund and the Chicago Community Trust