TRANSITIONAL CARE PROGRAM

FOR MORE INFORMATION: (715) 284-3646

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 Our Transitional Care Program, commonly referred to as “Swing Bed” by Medicare, is a stop between hospital and home, where patients get the continued skilled care they need to fully recover following a hospitalization. Our skilled staff provide around the clock, on-site care to help patients reach their end goal of returning home – independently and safely.

Personalized services are based off a patient’s individual needs and preferences. Each patient will be supported by their own personal care team throughout their stay.

The length of stay varies with each patient’s individualized needs.

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SERVICES

  • Skilled Nursing
  • Nutrition Services
  • Physical Therapy
  • Occupational Therapy
  • Pharmacy
  • Respiratory Therapy
  • Social Work
  • Speech Therapy

ADMISSION REQUIREMENTS

  • Patient must have been in an acute care hospital with a 3 midnight stay within the last 30 days. 
  • Patient must require skilled nursing services, skilled rehabilitation services, or respiratory needs:
    • Skilled Nursing Services: IV therapy, daily injections, extensive wound care, medical teaching, etc.
    • Skilled Rehabilitation Services: Physical therapy to gain strength to walk and/or move, or occupational therapy for management of daily activities.

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DISCHARGE PLANNING

  • Bedside rounding will occur on a weekly basis presenting the opportunity for the patient’s entire care team (family, patients, provider, RN, therapies, social services, etc.) to discuss goal progression.
  • Patients are allowed temporary leave from the facility to attend events, personal appointments, or visit their home with prior approval from staff. Temporary leaves are a good way to prepare for discharge and gauge how ready a patient truly is to return to independence.

CONTINUUM OF CARE:

  • Upon discharge, our care team will assist the patient with:
    • Establishing care with any necessary agencies
    • Scheduling follow-up appointments
    • Scheduling a visit with their primary care provider
    • Connecting patients with additional home health services if needed

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