Why We Need Transitional Care In India

Transitional care can be big support on the road to recovery for both the patient and caregiver. Here’s why it is the need of the hour.

When 68-year-old Nirmala* was diagnosed with pneumonia recently, she was rushed to the hospital by her family members. Her condition was under control within a couple of days but she faced poor mobility and needed continued antibiotic administration. This did not require hospitalization but Nirmala did require nursing care and the help of an active rehabilitation team. 

Such rehabilitation needs after hospitalization are often tough for caregivers to manage at home. This is when transitional care steps in. “This is something which cannot be managed at home by caregivers who are not formally trained and patients like Nirmala can be transferred to another facility where such a service is provided. This is what we refer to as transitional care. It is a system whereby a patient’s care is continued beyond the hospital to another facility. This may be rehabilitation, physiotherapy, or nursing needs,” says Dr. Steve Paul, Consultant Geriatrician, Apollo Hospitals, Bannerghatta Road. He believes that though it is extremely essential, especially in senior care, the concept of transitional care or intermediary care is barely known in India. 

What is transitional care?

The exact length of hospital stay is often unpredictable in eldercare. Even after a patient is stable, there may be unresolved issues. “In our system, currently the burden falls on the family, and patients are discharged home early before a complete rehabilitation is possible or the hospital stay is prolonged, impacting the financial resources, which may be already depleted,” Dr. Paul notes. 

Transitional care ensures that the treatment continues beyond the hospital to an intermediate facility until the patient is fit for discharge. 

How does this help the patient and caregivers?

• It promotes early discharge from hospitals to a nearby skilled nursing facility or a rehabilitation center.

• Saves hospital-related expenses and decreases the risk of contracting infections, especially during pandemic times.

• It is more convenient for the older adult’s family when resources are limited, such as the primary caregiver’s availability or when financially constrained.  

How does it help the management of care?

In India, the responsibility of care usually falls on the family who may have their challenges of work and time despite the best intentions. “Transitional care can ensure that older adults continue to receive supervised care closer to home, thereby facilitating the participation of the family,” says Dr. Paul. 

When does a patient need transitional care?

Patients preparing to be discharged undergo a comprehensive geriatric assessment. This multidisciplinary team evaluation assesses their independence in performing their Activities of Daily Living (ADL) and instruments of ADLs. If determined to require further physiotherapy support or nursing needs, (such as IV medications/wound dressing requirements), they are transferred to Intermediary Care (IC) which works as Transitional Care. Patients who require to be supervised for a week for catheter or stoma care also benefit from this until a possible ‘discharge to home plan’ is made.

What is the typical duration of stay and comparative cost with the hospital?

In India, private hospital beds can cost upwards of Rs 10,000 per day inclusive of room rent and clinical costs. Transitional Care beds cost between Rs 5000 to Rs 7,000 for standard packages. 

What’s next for Transitional Care in India?

Options to introduce transitional care need to be explored further in our country. Smaller clinics with 20-50 beds could be attached to the main hospital for receiving patients deemed fit for IC. An assessment team comprising of a geriatric physician, trained nurse, social worker, and physical and occupational therapist should evaluate the patient a week before the planned discharge.

Challenges to developing this system would be ill-equipped peripheral centers, dearth of trained professionals, lack of faith of the patient’s family in the transitional care center, and non-availability of medical insurance for non-hospitalized services.

Here’s a list of some of the Transitional Care providers in India

KITES Senior Care: KITES Senior Care is a Geriatric care Specialist brand and the first of its kind providing comprehensive ‘out of hospital care’ for elders both in their care facilities and in the comfort of the elders' home. Based in Bengaluru, KITES Senior Care has two centers with over 70 beds under its management in HBR Layout, North Bangalore, one providing transitional/rehabilitative care & palliative care and the other one being a dedicated dementia care facility.

KITES Senior Care’s transitional and rehabilitation care program covers a gamut of ailments and issues. These include post-hospitalization care, knee replacement rehabilitation, cancer care, hip joint replacement, post-CABG, post-COVID care, post-stroke rehabilitation, Parkinson's care, skilled nursing care, respite care, and supervised nursing care.

KITES Dementia Care Facility provides daycare and residential care for persons with Alzheimer’s and other forms of dementia. The program includes a memory clinic, cognitive retraining, and other allied services.

Whatever the condition/ailment, the KITES team ensures coordination and continuity of care for elders once they are out of the hospital.

At their care facilities, KITES offers varied services such as a structured care plan, 24X7 medical supervision, nursing care, nutrition, physiotherapy, geriatric counseling, and emergency management, among others.

Founded by senior doctors and healthcare professionals in 2016 with a vision of being trusted care partners to elders and their families. “Everything that we do at KITES Senior Care leads to enhancing the quality of life of the seniors who are under our care, be it at our centers or in the comfort of their own homes. Our processes and protocols, infrastructure planning, hiring, training, upskilling, all revolve around delivering superior care for seniors”, explains Mr. Rajagopal, Founder, and CEO of KITES Senior Care.

Know more here: www.kitesseniorcare.com

Contact here: 99800 67000

Aaji Care: Based in three locations across Mumbai in Andheri and Thane, with a fourth facility opening in Pune, Aaji Care was set up by Prasad Bhide to enhance elders’ quality of life. Aaji Care’s Transitional Care facility is offered at their assisted living facility/geriatric care centre called Aarambh. It is a long term care centre for the elderly with irreversible medical conditions, psychological conditions and post-operative care. The facility also acts as a bridge between the hospital and home for seniors who require medical intervention but do not need a hospital stay. At Aarambh, their physiotherapy needs, dietary needs, counselling and various aspects of caregiving are monitored, making rehabilitation easier in a friendly, community-oriented environment instead of an institutional facility. Patients are assisted in activities of daily living at every level, based on the requirement. The centre caters to patients with Dementia, heart disease, stroke, Parkinson’s Disease and post-operative care.

“We design activities and a daily routine for patients, including social interaction which works as a real medicine for many of them. They watch their peers eat, do activities, feel inspired to do the same, and often recover in that environment,” says Dr. Ruchi Raichura, Medical Administrator, Aarambh elder care home run by Aaji Care in Mumbai. 

Dr. Raichura shares the case study of a patient aged 79 who came to transitional care in a hypoglycaemic state after a hospital stay. With constant care, interactions, and activities around her, she was feeling better enough after a month to feed orally, communicate, have the catheter removed, and walk with support, signifying how transitional care helps in the overall improvement of care.

Know more here: www.aajicare.in

Contact here: 9920018184

Porvoo Transition Care: Located in Saket, New Delhi, it is a 16-bed facility providing critical care and post-operative care to patients requiring long-term support. The offerings include critical care, post-operative care, nursing care, physiotherapy, chemotherapy, immunotherapy, hormone therapy, diet and nutrition, diagnostics and radiology, in-house pharmacy, and more.   

Brinnova Care: Located in Banjara Hills, Hyderabad, Brinnova Transitional Care and Rehabilitation Centre is a 50-bed facility that offers neuro rehabilitation, cardiopulmonary rehabilitation, and orthopaedic rehabilitation, geriatric rehabilitation, oncology rehabilitation and palliative care. It also covers physical, occupational, speech therapies, post-operative rehabilitation and psychological counselling.   

HCAH SuVitas: Located in Hyderabad and Bengaluru, HCAH SuVitas brings in 50-bed transitional and rehabilitation care facilities in both cities. They specialize in inpatient rehabilitation for patients from neurology & neurosurgery, orthopedics, cardio sciences, and early-stage oncology. It also treats victims of stroke and road accident survivors with brain injuries and polytrauma. 

Sukino post-operative care: Located in Bengaluru, Sukino’s post-operative rehab center focuses on geriatric care and management of bed-ridden older adults. It offers general nursing, wound management, IV infusion therapy, fluid management, administering oxygen, nebulization, bed sore care, tracheostomy care, BiPAP/CPAP management, stoma care, and specialized feeding (Ryle’s Tube, PEG), and more.   

Have you tried any transitional care facility in India? Share your experiences with us in the comments below.

Cover image: Photo by Dominik Lange on Unsplash