TRANSITIONAL CARE PROGRAM
getting you back to health
Where do you go after an illness, accident, or surgery when you no longer need to be in the hospital but can’t yet manage on your own at home? Traditionally, the solution for interim post-hospital care has been a nursing home. Which is not optimum for most people.
If you’re in a transitional care situation and need a place to continue your recovery, OMC has a private room for you—with everything you need right here to get you back to health and back to your life as soon as possible.
René Milner, MD
Family Medicine
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Benefits of Hospital-based Transitional Care
When you’re in the program, you’ll receive:
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A dedicated care team there to provide the highest level of personalized care (and you’ll be closer to home!)
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Daily bedside rounds with your care team that include your family, so everyone is informed of your progress and what is still needed to reach your goals.
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Hospital-level nurse staffing to tend to all your daily needs.
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Individualized activity programs and rehabilitation therapies in a comfortable environment that welcomes and accommodates your family.
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On-site physician, therapy, radiology, laboratory, and pharmacy teams to address all your medical needs.
THE PROGRAM PROVIDES:
Care After Complex Surgery
Cardiac, neuro, orthopedic, abdominal surgery, and more
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Respiratory Treatments for patients with breathing problems
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Wound Care for complex and slow-healing wounds
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Intravenous Antibiotics for patients with serious infections
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Physical, Occupational & Speech Therapy
and other supportive services
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your questions, answered
How long can I stay in transitional care?
While transitional care patients may stay as long as two or three months, most of the patients stay somewhere between 10 to 14 days. Patients with significant needs can stay longer. After a stay in transitional care, over 70% of patients are discharged back to their home or assisted living facility.
What happens if I’m unable to go home?
If, after transitional care, you have significant ongoing needs, we will help you find the long-term care solution that’s best for you.
Who manages my care after I return home?
Your primary care clinician will help you continue your recovery after you return home. OMC’s team of rehab specialists will see you on an outpatient basis as needed.
Can I afford transitional care?
Yes, you can! Most transitional care is reimbursed under the Medicare Part A Swing Bed program. As long as skilled needs are present, the program will reimburse for up to 100 days of facility-based care after you’re discharged from the hospital. Transitional Care may also be covered through private insurance or Medicare supplements. Please contact our Critical Access Hospital Transitional Care coordinator for more information on coverage!
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How do I get started?
Most of the time patients are referred by other hospitals/social workers, but patients and families can contact us at xx.
What makes Critical Access Hospital-based Transitional Care the best option for many patients?
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Greater safety, quality, and flexibility than other post-acute settings because of hospital services and resources available such as on-site physicians, respiratory therapy, lab, and radiology.
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Hospital-level nurse and rehabilitation therapy staffing levels (two to three times more nursing hours per patient per day than many other settings).
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Effective rapid assessment and transfer processes, when needed.
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Patient family members are able to be engaged when post-acute care is closer to home.
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The CAH setting, where most staff know and trust each other (both at and outside of work), fosters a culture of teamwork and collaboration.
What does CAH-based Transitional Care look like?
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While transitional care patients may stay as long as two or three months, most of the patients stay somewhere between 10 to 14 days.
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After a stay in Transitional Care, over 70% of patients are discharged back to home or assisted living.
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Some patients spend time in Transitional Care to determine whether or not they will be able to recover or maintain the ability to live independently. In some cases, discharge to long term care is the safest outcome for patients and families.