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

Patients commonly experience a complete new set of caregivers as they progress from acute to subacute care settings. As a result, managing continuity of care, patient satisfaction, and cost containment across the rehabilitation continuum becomes impossible. In addition, accountability for overall outcomes is fragmented, and patients often feel abandoned by their primary caretakers. To eliminate these problems, a rehabilitation liaison nurse followed patients from the acute to subacute setting. A mutually beneficial partnership evolved between the facilities. Continuity of care improved, transdisciplinary teams shared resources, the subacute length of stays decreased significantly, and patients gained a sense of support throughout the continuum of care. This article describes the development of an extended pathway, clinical implications for rehabilitation of joint replacement patients, some unexpected outcomes, and the role of a rehabilitation liaison nurse.