Transitional Care
Skilled Nursing/Swing Bed
What is Transitional Care:
Transitional care provides a supportive bridge for patients who no longer need acute hospital treatment but are not yet ready to return home safely. This short-term level of care allows patients to continue recovering in a hospital-based setting while receiving the medical attention, nursing support, therapy, and assistance they need to regain strength and independence.
Through transitional care, patients may receive skilled nursing services and short-term rehabilitation following surgery, hospitalization, illness, or an injury. Care is tailored to each patient’s condition and goals and may include medication management, monitoring of ongoing health needs, assistance with daily activities, mobility support, physical rehabilitation, and coordination of follow-up care. The goal is to promote steady progress while reducing the risk of setbacks or complications during the transition from hospital care to home.
How Transitional Care Works:
A team of healthcare professionals works with the patient and family to develop an individualized plan of care. This plan focuses on improving function, building confidence, managing medical conditions, and preparing the patient for a safe discharge. Patients benefit from continued clinical oversight in a comfortable, structured environment where their changing needs can be addressed promptly.
Transitional care can be especially helpful for individuals who need additional time to recover after a procedure, regain mobility after an illness or injury, complete therapy, or learn how to manage a new or ongoing health condition. By combining skilled nursing care with rehabilitation and discharge planning, the program supports a seamless continuum of care and helps patients return to their daily routines as safely and independently as possible.
Admission Criteria:
A physician who is a member of the Medical Staff here at the hospital accepts your admission to the Transitional Care Program.
Criteria required to process your admission:
- Your physician must certify that you require skilled level of care.
- Your condition must be rehabilitative in nature.
- You must show reasonable signs of improvement with skilled intervention.
- To be eligible for Medicare coverage for a skilled stay, you must have occupied an acute (hospital) bed for at least three consecutive days, not including the day of discharge, within the last 30 days.
- A chest X-ray showing you are free of TB.
- Admission criteria must be related to the admitting diagnosis for your acute care stay.
- An admission agreement will be required prior to admission.
Additionally, staff will interview you to discuss your skilled needs, requests, and goals, including your discharge plans. If you have an advance directive, the hospital will need a copy for your medical record.
The hospital will only accept you into the Transitional Care program if it has the facilities and staff to meet your needs.
Skilled Nursing Services Include:
- In-depth assessments and care planning
- Postoperative care and monitoring
- Pain management
- Injections
- Intravenous therapy (IV)
- Total parenteral nutrition (TPN)
- Tube feeding
- Antibiotics
- Wound care
- Rehabilitation
- Patient education and training
Some Services You May Need To Include:
- Physical Therapy
- Occupational Therapy
- Speech Therapy
