Transitional Rehab Care

Jackie McKenzie

Hamilton Memorial Hospital Rehabilitation staff with graduated Extended Care Swing Bed patient (l-r)Glenna, PTA; Katie, Physical Therapist; Katie, Occupational Therapist; Jackie, patient; Lisa, PTA; Lyndsi COTA; Cande, COTA

 

Department information

For more information regarding the Hamilton Memorial Hospital Transitional Rehab Care, call Director of Social Services at 618.643.2361 ext.2145.

What is a “Transitional Rehab” Care?

Hamilton Memorial Hospital’s Transitional Rehab Care program is especially designed for Medicare, Commercial insurance, and even Medicare Advantage  patients to stay in the hospital under skilled care while receiving intensive physical, occupational, and/or speech therapy. The term “swing bed” is also used to describe this transitionary period that the patient stays in the hospital, but receives intensive therapy to ready them for a return home. 

Who qualifies for Transitional Rehab Care?

Patients must meet certain criteria to be eligible for this program. 

The patient must have been hospitalized in an acute care setting for three days within the past 30 days of seeking admission to the program.  The patient must also need continuing treatment including physical therapy, IV medications, respiratory therapy, speech therapy, occupational therapy, or extensive nursing care. 

What type of patients are accepted?

People who might benefit from this program are those that have variety of diagnosis’ including hip fractures, stroke, joint replacement, prolonged recovery from surgery, severe wounds that require skilled treatments and nursing care, or need short-term antibiotic therapy. They also must have been hospitalized for at least 3 days in the last 30 days.

How is a patient admitted?

Patients are accepted for this program from other acute care hospitals as well as Hamilton Memorial Hospital. 

For example, if a patient received a hip or knee replacement at another hospital, a case manager from that facility could contact Hamilton Memorial Hospital. At that point, the Transitional Rehab Care team consisting of nursing, an advance practice provider, physical therapy, and case management staff would determine the patient’s eligibility for admission. 

Do I have a choice? 

As the patient, you always have the right to choose where you will go for skilled care. 

How long can a patient stay in the Transitional Rehab Care program?

This program is designed to be relatively short term. Although a patient has a total of 100 Medicare covered days, no patient automatically received 100 days for a stay. The length of stay depends on the patient’s progress in meeting treatment goals. When the patient has reached a point where treatment goals are met or where there has not been any more significant progress, the patient is ready for discharge from the program. 

What happens when the patient is ready to go home?

The Transitional Rehab Care team at Hamilton Memorial Hospital meets regularly to check on the patient’s progress and encourage the patient and family to meet and participate in the planning. When the teams feels the patient is ready to go home, they will contact the physician or advance practice provider for their input and approval. 

The patient and their family will be notified of the planned discharge date. Home health services may be ordered by the provider to continue the patient’s treatment or therapy, if needed. 

Why choose the Hamilton Memorial Hospital Transitional Care Rehab program?

There are a number of reasons to choose the program at Hamilton Memorial Hospital:

  • Close to home – making it more convenient for family and friends to visit
  • Access to Hospitalist medical provider 7 days a week
  • Staff is local and dedicated to treating patients like family
  • Modern facilities – ensuring patients get the care they need
  • Private room and bathroom
  • Activities programs that are geared to patients interests
  • Skilled nursing care in the hospital setting, not a nursing home

What is the physician and/or advance practice provider role in the program?

The physician and/or advance practice provider will do an initial visit to evaluate your condition and initiate a plan of care. The provider will set their own schedule of visiting the patient; it may not be everyday. However, any time the nursing staff feel that patient needs to be seen they will contact the provider and ask them to do so.