The essential role of the rehabilitation nurse in facilitating care transitions: A white paper by the association of rehabilitation nurses

Rehabilitation Nursing

Volumn 39, Issue 1, 2014, Pages 3-15

  Camicia, Michelle ^a   Black, Terrie ^a   Farrell, James ^a   Waites, Karion ^a   Wirt, Susan ^a   Lutz, Barbara ^a   Wildermuth, Jordan ^a  

^a Health Policy and Advocacy Manager   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HEALTH CARE POLICY; HUMAN; NURSE ATTITUDE; NURSING EDUCATION; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PRACTICE GUIDELINE; REHABILITATION NURSING; STANDARD;

CONTINUITY OF PATIENT CARE; EDUCATION, NURSING, CONTINUING; HUMANS; NURSE'S ROLE; PATIENT CARE TEAM; PATIENT PROTECTION AND AFFORDABLE CARE ACT; PRACTICE GUIDELINES AS TOPIC; REHABILITATION NURSING;

EID: 84891845902     PISSN: 02784807     EISSN: 20487940     Source Type: Journal    
DOI: 10.1002/rnj.135     Document Type: Article

References (37)

1. Agency for Healthcare Research and Quality (AHRQ). (2013). Outpatient case management for adults with medical illness and complex care needs. Retrieved November 17, 2013, from http://www.effectivehealthcare.ahrq.gov/ehc/ products/240/1677/case-management-clinician-130828.pdf
2. American Hospital Association (AHA). (2013). Retrieved November 17, 2013, from http://www.aha.org/research/reports/tw/chartbook/2013/chapter3.pdf
3. American Nurses Association (ANA). (2012). The value of nursing care coordination. Silver Spring, MD: Author.
4. Association of Rehabilitation Nurses. (2006). Staff Nurse Role Description. Retrieved November 17, 2013, from http://www.rehabnurse.org/ uploads/files/uploads/File/rdstaffnurse11.pdf
5. Association of Rehabilitation Nurses. (2008). Standards and scope of rehabilitation nursing practice. Glenview, IL: Association of Rehabilitation Nurses.
6. Association of Rehabilitation Nurses. (2010). Rehabilitation: The rehabilitation nurse case manager role description. Retrieved November 17, 2013, from http://www.rehabnurse.org/uploads/files/uploads/File/rdcasemgmt11.pdf
7. Centers for Medicare and Medicaid Services (CMS). (2010). Medicare benefit policy manual. Retrieved November 17, 2013, from http://www.cms.gov/ Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf
8. Centers for Medicare and Medicaid Services (CMS). (2012). What is long-term care? Retrieved November 17, 2013, from http://www.medicare.gov/ longtermcare/static/home.asp
9. Centers for Medicare and Medicaid Services (CMS). (2013a). Revisions to state operations manual (SOM), hospital appendix A-interpretive guidelines for 42 CFR 482.43, discharge planning. Retrieved November 17, 2013, from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-32.pdf
10. Centers for Medicare and Medicaid Services (CMS). (2013b). Transitional care management services fact sheet. Retrieved November 17, 2013, from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet- ICN908628.pdf
11. Chan, L., Sandel, E.M., Jette, A.M., Appelman, J., Brandt, D.E., Cheng, P., et al. (2013). Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke Physical Medicine and Rehabilitation, 94, 622-629.
12. Chugh, A., Williams, M. V., Grigsby, J., &, Coleman, E. A., (2009). Better transitions: Improving comprehension of discharge instructions. Frontiers of Health Services Management, 25 (3), 11-32.
13. Congressional Research Service (CRS). (2010). Medicare hospital readmissions: Issues, policy options and PPACA. Retrieved November 17, 2013, from http://www.hospitalmedicine.org/am/pdf/advocacy/crs-readmissions-report.pdf
14. Deutsch, A., (2013). Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke [Review of does postacute care site matter? A longitudinal study assessing functional recovery after a stroke by Chan, et al. 2013] Physical Medicine and Rehabilitation, 94, 630-632.
15. Deutsch, A., Granger, C.V., Heinemann, A.W., Fiedler, R.C., DeJong, G., Kane, R.L., et al. (2006). Poststroke rehabilitation: Outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs. Stroke, 37, 1477-1482. doi: 10.1161/01.STR.0000221172.99375.5a (Pubitemid 44305729)
16. Dossa, A., Bokhour, B., &, Hoenig, H., (2012). Care transitions from the hospital to home for patients with mobility impairments: Patient and family caregiver experiences. Rehabilitation Nursing, 37 (6), 277-285. doi: 10.1002/rnj.047
17. Gage, B., (2009). Post acute care: Moving beyond the silos [PowerPoint slides]. Retrieved November 17, 2013, from http://www.rti.org/files/ fellowseminar/fellowseminar-longtermcare-gage/pdf
18. Granger, C.V., Markello, S.J., Graham, J.E., Deutsch, A., &, Ottenbacher, K.J., (2009). The Uniform data system for medical rehabilitation: Report of patients with stroke discharged from comprehensive medical programs in 2000-2007. American Journal of Physical Medicine & Rehabilitation, 88 (12), 961-972. doi: 10.1097/PHM.0b013e3181c1ec38.
19. Grobowski, D.C., Huckfeldt, P.J., Sood, N., Escarce, J.J., &, Newhouse, J.P., (2012). Medicare post acute care payment reforms have potential to improve efficiency of care, but may need changes to cut costs. Health Affairs, 31 (9), 1941-1950. doi: 10.1377/hlthaff.2012.0351.
20. Huang, H. T., Chang, C. M., Liu, L. F., Lin, H. S., &, Chen, C. H., (2013), Trajectories and predictors of functional decline of hospitalized older patients. Journal of Clinical Nursing, 22 (9-10), 1322-1331. doi: 10.1111/jocn.12055.
21. Institute of Medicine. (2013). Variation in health care spending: Target decision making not geography. Retrieved November 17, 2013, from www.iom.edu/Reports/2013/.
22. Larsen, P., (2011). The environment for rehabilitation nursing. In, C. Jacelon, (Ed.), The Specialty Practice of Rehabilitation Nursing: A Core Curriculum (6th ed., pp. 507-511). Glenview, IL: Association of Rehabilitation Nurses.
23. Lutz, B. J., Young, M. E., Cox, K. J., Martz, C., &, Creasy, K. R., (2011). The crisis of stroke: Experiences of patients and their family caregivers. Topics in Stroke Rehabilitation, 18 (6), 786-797. doi: 10.1310/tsr1806-786.
24. Mallinson, T.R., Bateman, J., Tseng, H.Y., Manheim, L., Almagor, O., Deustch, A., et al. (2011). A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery. Physical Medicine and Rehabilitation, 92 (5), 712-720. doi: 10.1016/j.apmr.2010.12.007.
25. Medicare Payment Advisory Commission (MedPAC). (2011). Report to the Congress. Retrieved November 17, 2013, from http://medpac.gov
26. Medicare Payment Advisory Commission (MedPAC). (2012). Report to the Congress. Retrieved November 17, 2013, from http://medpac.gov
27. Medicare Payment Advisory Commission (MedPAC). (2013). Report to the Congress. Retrieved November 17, 2013, from http://medpac.gov
28. Mor, V., Intrator, O., Feng, Z., &, Grabowski, D.C., (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, (1), 57-64.
29. National Cancer Institute (NCI). (2013). NCI dictionary of cancer terms. Retrieved November 17, 2013, from http://www.cancer.gov/dictionary
30. Nelson, A., (2007). Nurse staffing and patient outcomes in inpatient rehabilitative settings. Rehabilitation Nursing, 32 (5), 179-202.
31. Nursing Alliance for Quality of Care (NAQC). (2013). Fostering successful patient and family engagement. Retrieved November 17, 2013, from http://www.naqc.org/Main/Resources/Publications/March2013- FosteringSuccessfulPatientFamilyEngagement.pdf
32. Sandel, M.E., (2012). What's on the horizon: The rehabilitation hospitalist. Physical Medicine and Rehabilitation, 4 (1), 1-3. doi: 10.1016/j.pmrj.2011.12.005.
33. Sandel, M.E., Wang, H., Terdiman, J., Hoffman, J.M., Ciol, M.A., Sidney, S., et al. (2009). Disparities in stroke rehabilitation: Results of a study in an integrated health system in northern California. Physical Medicine and Rehabilitation, 1, 29-40. doi: 10.1016/j.pmrj.2008.10.012.
34. Seneff, M.G., Wagner, D., Thompson, D., Honeycutt, C., &, Michael, R., (2000). The impact of long-term-acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation. Critical Care Medicine, 28 (2), 342-350. (Pubitemid 30120870)
35. U.S. Department of Health and Human Services (HHS). (2012). National strategy for quality improvement in health care. Retrieved November 18, 2013, from http://www.ahrq.gov
36. Wang, H., Camicia, M., Terdiman, J., Hung, Y. Y., &, Sandel, E., (2011). Time to inpatient rehabilitation hospital admission and functional outcomes of stroke patients. Journal of Physical Medicine and Rehabilitation, 3, 296-304.
37. Wang, H., Camicia, M., Terdiman, J., Mannava, M.K., Sidney, S., &, Sandel, M.E., (2013). Daily treatment time and functional gains of stroke patients during inpatient rehabilitation. Physical Medicine & Rehabilitation, 5, 122-128.