Preston Memorial Hospital offers a Transitional Care Program as an alternative to prolonged acute hospitalization or short term nursing facility placement for post-acute extended care. The program provides skilled nursing care and rehabilitation services. This may include IV therapy, medication management and therapy services. As a team, they follow a written plan of care to help each patient achieve and maintain their optimum level of independent functioning. The team includes a hospital based Provider, working in consultation with the patient's referring physician; Skilled Nursing Staff; a Case Manager; an Activities Coordinator; Physical, Occupational, Respiratory and Speech Therapists; a Dietitian; and other professional referrals as needed. As a hospital-based program, Transitional Care patients have access to 24 hour nursing staff, along with in-house therapists, pharmacy, and emergency services.
In order to qualify for the Transitional Care Program, a patient must meet the following requirements:
• Be covered by Medicare Part A (or have another insurance plan that covers this service)
• Have had 3 overnights in an acute care bed prior to utilizing the Transitional Care services
• Have an ongoing diagnosis and needs that require skilled care as defined by Medicare
Common diagnoses treated in this program include patients with extended IV therapy needs, orthopedic surgeries (hip/knee replacements), fractures, post-surgical procedures, neurological disorders (stroke), and generalized weakness due to CHF, COPD, pneumonia, and other chronic conditions
Length of Stay
The length of stay in our Transitional Care Program is dependent upon individual patient needs and progress. Average length of stay is 5-10 days. Our Transitional Care Program is not intended for permanent placement; it is for continued care until the patient returns home or transfers to a facility for longer term care.
Patients are discharged from Transitional Care Program when:
• They have achieved the maximum benefit of skilled nursing or rehabilitation, as determined by the physician
• The care being provided has become custodial in nature
• The patient’s continuing care requires long term rehabilitation placement
• There is a change in the patient’s needs/level of care
Kristina Kark, RN, MSN Case Management/Utilization Review Director