Transitional Care

Monument Health’s Transitional Care Program provides skilled nursing care and rehabilitation services for patients who are discharging from the hospital but still need temporary assistance that cannot be provided at home or in a typical skilled nursing facility. The program is designed to assist the patient in becoming as independent as possible before discharge.

Once able to safely discharge, they work with the patient’s primary care provider to coordinate any in-home services needed.

To qualify for the Transitional Care Program, the following requirements must be met:

Have had three inpatient overnights in an acute care bed prior to the Transitional Care Program.
Have an ongoing diagnosis and needs that require skilled care as defined by Medicare.

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PROGRAMS

Home+ Home Care

Provided in the comfort of your home
Multidisciplinary team approach to care
24/7 availability to a registered nurse to answer questions
Case management for chronic health problems
Intermittent nursing visits scheduled to meet your needs
Therapy visits scheduled to meet your needs

CRITERA

Within Home+ Home Care service area
Skilled care such as IV antibiotics, wound care, therapy needs
Medicare and most insurances pay 100%
Leaving home may be difficult
Can accommodate multiple medical conditions
Short- or long-term stay

Nursing Home

Private and semi-private rooms
Provider access 3 days/week
Therapy 6 days/week
Average length of stay 23-48 days
Multidisciplinary team approach to care

CRITERIA

3 day hospital stay*
Able to participate and progress with therapies
Skilled care such as IV, wound care, therapy needs
Can accommodate multiple medical conditions
Short- or long-term stay

Hospital-Based Transitional Care

Private room
Provider visit at least every 7 days with 24/7 availability
Therapy available 5 days/week
Average length of stay 13-15 days
Multidisciplinary team approach to care
Nurse ratio – 1 nurse:4-5 patients

CRITERIA

3 day hospital stay*
Able to participate and progress with therapies
Skilled care such as IV, wound care, therapy needs
Can accommodate multiple medical conditions
Short- or long-term stay

Hospital-Based Rehabilitation

Private room
Minimum 3 face-to-face visits with provider/week*
Therapy available 7 days/week
Average length of stay 12-14 days
Multidisciplinary team approach to care*
Nurse ratio – 1 nurse:5-6 patients

CRITERIA

3 day hospital stay not required
Medically able to tolerate and participate in three (3) hours of multidisciplinary therapy per day and have the potential to significantly improve*
Skilled care such as IV antibiotics, wound care, medically complex care and at least two disciplines of therapy needed*
Have a qualifying rehabilitation diagnosis – primary focus on 13 medical conditions*
Short-term stay

*based on Centers for Medicare and Medicaid Services, some insurances may differ