Transitional Care is for patients who are ready to be discharged from a traditional acute-care hospital but aren’t quite ready to go home. These patients still require additional skilled medical care, nursing care, or rehabilitation services.
Our team is equipped to care for patients with complex needs, including:
- After Surgery: Cardiac, neuro, orthopedic, abdominal, and more
- Respiratory: Specialized treatment and support
- Wound Care: Special attention for wound healing
- Intravenous (I.V.) Antibiotics: To treat a variety of infections
- Specialized Therapy: Including physical therapy and an array of supportive services
- Teaching and Training: Education on management of new complex conditions
- Coordination and Ongoing Assessment of Complex Plans of Care: RN oversight and team collaboration to modify care plans as frequently as patients need
Our program is supported with evidence-based best practices through a partnership with Allevant Solutions developed by Mayo Clinic and Select Medical.
- A personalized plan of care
- Bedside rounds that engage you, your family, and your care team to help you reach your goals
- Hospital-level nurse staffing to keep you safe and help you recover
- A home-like environment that accommodates patients and participation in activity and rehabilitation
- On-site advanced practice providers, physical therapy, radiology, and laboratory that will address your specific needs
Our Transitional Care Program is centered on teamwork, communication, and collaboration. Your care team will work with you and your loved ones on a personalized plan, support your goals, and meet with you on a regular basis to celebrate successes and adjust the plan.
Frequently Asked Questions:
How long do patients typically stay in Transitional Care?
Most stays in Transitional Care are a few days to a few weeks, however, some patients may stay for up to 100 days if they have daily qualifying skilled care needs. The majority of patients in our program improve their health and rehabilitation status during their stay, and the majority of program patients who lived at home prior to their hospitalization are discharged back home after Transitional Care.
Is Transitional Care covered by my insurance plan?
Transitional Care is predominantly covered by the Medicare “Swing Bed” benefit. Some other insurance providers may cover this care as well. If you are having a planned hospitalization and think you might need care after your stay, we can check if Transitional Care would be covered so you can plan ahead of time to come to our programs.
Why is the program called “Transitional Care” and is it the same as “Swing Bed”?
Our program is called Transitional Care because it is a model focused on helping patients transition from a hospital stay to their highest level of independence at home or in another setting. We use hospital-level resources, team processes, best practices, and extra clinical education to support this “transition”. Since most patients receive this care under Medicare, this level of care is sometimes also referred to as “Swing Bed.”
How is Transitional Care different from the care received at a Skilled Nursing Facility or nursing home?
Because we are a hospital, we can deliver Transitional Care with high levels of safety, quality, and flexibility with hospital-based resources including on-site lab, radiology, and immediate access to physicians and other caregivers. Our hospital-based Transitional Care program provides up to 2 - 3 times more available nurse hours per patient day compared to most skilled nursing facilities. We hold Bedside Rounds with patient, family and care team together on a scheduled basis, so everyone understands your plan of care, identifies things that need to be addressed, and plans for a safe discharge.