September 4, 1998 

Charles Pu, MD

The MGH Geriatrics Unit, the Adult Medicine Department at the MGH·Chelsea HealthCare Center and the Operations Improvement nonacute care team recently inaugurated a pilot program that will help facilitate the transfer and management of MGH patients who require short-term stays at skilled nursing facilities.

Directed by Charles Pu, MD, the Transitional Care Program will provide a system for MGH physicians to follow their patients in a skilled nursing setting. Pu is supported by Lynne Brodsky, MD, and Terry O'Malley, MD, of MGH·Chelsea, as well as geriatric adult nurse practitioners Alice Chaput, RN, and Maureen Picard, RN.

In this pilot program, the Transitional Care team sees patients at skilled nursing facilities such as EastPointe and On Broadway in Chelsea; Don Orione in East Boston; and Lighthouse in Revere.

The Transitional Care team collaborates with the MGH case management staff to identify patients who should be cared for in a skilled nursing setting and ensure their timely transfer. Pu and his colleagues work closely with patients and their families to answer questions and discuss treatment plans. The team also is available to MGH clinicians for consultations about patients before and after transfers are made.

At first the program will concentrate on patients going to EastPointe, which receives about half of its admissions from the MGH. Coverage at the other facilities will be provided on a volume-permitting basis.

"The Transitional Care Program is a natural extension of the MGH Geriatrics Unit and of the acute care environment," says Pu. "It is an important and effective way of closing the medical loop for our frail elderly patients and an enormous asset to the hospital under managed care."

For more information, contact Pu at (617) 877-4615.