top of page

Transitional Care Program


Supporting patients recovering from an acute illness or surgery who no longer require acute hospital care but are not yet ready to go home.

We will work closely with your discharging acute care hospital to ensure a safe transition to our Transitional Care Program.


We provide you with the highest quality care close to home.

  • 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 meet your needs.

  • Promotes a home-like environment accommodating family and individualized activity programs, as well as therapy in several environments.

  • Our on-site physician, therapy, radiology, laboratory and pharmacy teams will address all your medical needs.

The program can help:

After Complex Surgery

Cardiac, neuro, orthopedic, abdominal care and more.

Respiratory Needs

Specialized treatments and support.

Wound Care

Special attention for wound healing.

Intravenous Antibiotics

Also known as an I.V. to treat a variety of infections.

Quality and Safety

Including physical, occupational, speech and respiratory and an array of supportive services.

OMC Transitional Care Program is supported with evidence based best practices through a partnership with Allevant Solutions developed by Mayo Clinic and Select Medical.

What should patients expect?

Patients and families will join the full care team for bedside team rounds at least weekly to support goal identification and attainment, celebrate successes, discuss challenges, and ensure progression towards a safe discharge.   Patients and families will notice excellent nurse staffing (fewer patients per nurse).  Patients will be encouraged to maximize their activity, spend time outside of their room, and if possible, socialize with other patients.

What makes Critical Access Hospital-based Transitional Care the best option for many patients?

  • 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.

  • Hospital-level nurse and rehabilitation therapy staffing levels (two to three times more nursing hours per patient per day than many other settings).

  • Effective rapid assessment and transfer processes, when needed.

  • Patient family members are able to be engaged when post-acute care is closer to home.

  • 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? 

  • While Transitional Care patients may stay as long as two or three months, most of the patients stay somewhere between 10 to 14 days.

  • Transitional Care stay, (71) % of them were discharged back to home or assisted living.

  • 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, and in some cases, discharge to long term care is the safest outcome for patients and families.

How is CAH-based Transitional Care paid for?

Most CAH Transitional Care is reimbursed under the Medicare Part A Swing Bed program.  If criteria are met, Medicare Swing Bed will reimburse for up to 100 days of post-acute care as long as skilled needs are present.  Some patients may qualify for Transitional Care reimbursement via other programs or payers. When in doubt, please contact our Critical Access Hospital Transitional Care program and inquire about reimbursement options.


We’ll answer any questions you may have and enroll you in the program. Once you are enrolled, a nurse will review your medical history, and will be well prepared for your first conversation.

All About Appointments

Everything you need to know about scheduling your next appointment, whether scheduling online or coordinating a specialist referral, we've got you covered.

Patient Online Services

Managing your health care just got easier, with Patient Portal. Get access to your records, schedule online appointments and chat with your healthcare team.

While You're Here

The OMC campus has more to offer than you might expect! We've got a cafe with delicious fresh food, shop, walking trail and playground. Check out what we have to offer!

bottom of page