Transitional Care

What Is Transitional Care?

Transitional Care helps patients who are ready to be discharged from a traditional acute-care hospital but aren’t quite ready to go home. Most patients in transitional care stay for a few days up to a few weeks up to as long as 100 days if they have daily qualifying skilled care needs. Most patients in our program improve in health and are discharged back home after transitional care.

For admission inquiries, please call us at (406) 323-4929 or send a fax at (406) 323-4937.

Roundup Memorial Healthcare follows evidence-based best practices to provide personalized plans of care to engage the patient, their family, and their treatment teams to help patients reach their healthcare goals. While in recovery, our hospital-level nurse staff keeps patients safe as they relax in a home-like environment and take part in activities such as inpatient rehabilitation. On-site advanced practice providers, physical therapists, radiologists, and laboratory specialists will be on hand to address each patient’s specific needs. Patient care is designed to support each individual’s unique goals and adjust them on a continuous basis.

While patients are in transitional care, they are able to receive additional skilled medical care, nursing care, or rehabilitation services.

Our medical staff cares for patients with complex needs, such as:

• Post-operatively after cardiac, neurologic, orthopedic, abdominal, and other surgeries
• Respiratory assistance for specialized support
• Wound care totreat for non-healing wounds
• Intravenous (IV) antibiotics to treat a variety of infections
• Physical therapy and an array of supportive services
• Patient education on the management of complex health problem
• Coordination and ongoing assessment for complex care plans from registered nurses who oversee a team and modify plans as often as necessary

Transitional Care: Frequently Asked Questions

Is Transitional Care covered by healthcare insurance?

Transitional Care is often covered by Medicare “Swing Bed” benefit coverage, but other insurance providers may offer this benefit, too. If you have a planned upcoming hospitalization and think you might need transitional care before you can go home, Roundup Memorial Healthcare can verify for you ahead of time if transitional care is a covered benefit on your plan.

Are Transitional Care and Swing Bed Programs the same thing?

Because many of the patients receive transitional care under Medicare coverage, transitional care is sometimes also referred to as “Swing Bed.”

Transitional Care is a treatment model focused on helping patients transition from their inpatient hospital stay to their highest level of independence before they are discharged home. We use hospital-level resources, team processes, best practices, and extra clinical education to support this “transition.”

Is the Transitional Care Program different from a Skilled Nursing Facility or nursing home?

Roundup Memorial Healthcare is a hospital that can deliver Transitional Care with the highest levels of safety, quality, and flexibility, not to mention the wealth of resources the hospital has, such as our on-site lab, imaging tests, and immediate access to doctors and medical staff. Our patients typically have more than 2 to 3 times as many nurse hours per patient per day compared to most skilled nursing facilities. These nurses hold bedside rounds with patients, family, and the care team together on a routine basis. During these rounds, they make sure everyone is on the same page regarding their understanding of your care plan while identifying anything that need to be addressed before planning your safe discharge.