Transitional Care Unit

Contact Information

Amy Rottger, RN, BSN
Patient Service Supervisor
315-492-5041
RottgerA@upstate.edu

The Transitional Care Unit (TCU) at University Hospital Community Campus is a 20 bed hospital based short-term sub-acute skilled nursing unit. The unit, which plans to open in July 2014, is located on the completely renovated 5E unit on the Upstate Community Campus. The TCU admits only Medicare patients directly from an Upstate University Hospital acute care unit.

The TCU provides services to inpatients that no longer require acute care, but continue to need specialized medical, nursing and other hospital ancillary services and are not yet ready for discharge. It will be necessary for the patient or family to participate in the care on the TCU and to effectively address the post-discharge needs.

Examples of Medicare patients considered for admission to TCU include:

  • Patients with general diagnoses in Orthopedics/Neuroscience/Surgical/Medical requiring short-term, therapies to improve mobility, self-care, ADL, bladder/bowel management, communication, balance, or safety.
  • Surgical Cases requiring Complex Wound Care/New colostomy patients requiring patient/caregiver education.
  • Patients who require IVs, tube feeding, daily injections and therapies, sterile dressing changes, nutritional assessments or skilled medical observation.
  • Endocrine patients with newly diagnosed diabetes requiring patient/caregiver education.
  • Deconditioned Patients requiring Respiratory or Cardiovascular care.
  • Patients with Systemic infections requiring intravenous antibiotics or antifungal agents, PN or intermittent lipid therapy and End stage diseases.

It is expected that patients admitted to the TCU will remain on the unit between five and 21 days. During their stay, care will be delivered by a comprehensive interdisciplinary team of Registered Nurses, Licensed Practical Nurses, occupational, physical, speech and recreational therapies, case management, and social work staff. In addition, staff members from ancillary areas of the hospital (for example, laboratory, radiology, food and nutrition, respiratory services, social services, chaplaincy services) also assist patients and their families as appropriate. The team will work under the direction of nursing/hospital administration and also Upstate's Division Chief of Geriatrics, Sharon Brangman, MD.

Nurses in the TCU provide focused care to patients who are not ready to be discharged home or to another facility. Our nurses work to coordinate patient care amongst many different disciplines including OT/PT, dietary, and social work. All RN's receiveĀ a 10- 16 week competency based orientation with an assigned preceptor. Orientation includes both classroom and hands-on learning. In addition, as a Nurses Improving Care of Healthsystem Elders (NICHE) Hospital, the nursing staff will have access to the NICHE on line learning center.