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What is a Transitional Care Program?
Transitional Care is a skilled nursing rehab program designed to provide you with compassionate sub-acute care* and physical rehabilitation** when you have been in the hospital but are not yet well enough to go home. Our goal is to help you reach your optimal level of strength and functioning so you may return to your own home or residential facility.

*Sub-Acute Care is for patients who are discharged from a hospital and need temporary additional care that cannot be provided at home or in a long-term care facility.
**Physical rehabilitation is the process of regaining function and strength following illness or trauma.

Who Qualifies for the Transitional Care Program?
Medicare and most insurance companies cover sub-acute rehabilitation services. The services are usually covered under the “Skilled Nursing Facility” benefit category. Medicare and state regulations provided the following patient eligibility guidelines:

  • A patient must be hospitalized for a minimum of three consecutive midnights.
  • Admissions can come from any hospital, including our hospital.

We advise you to contact your insurance company for specific coverage before making any health care decisions. Your case manager can assist you with the process.

Who Is Involved in Your Care?
Physicians: Board certified Internal Medicine physicians, or hospitalists, care for each patient and are available 24 hours a day. These physicians may also consult with other specialists during your stay.

Nurses: Our skilled nurses provide individualized care to each patient. Our registered nurse case manager coordinates with the referring facility to assure that you experience a smooth transition into our program. Your case manager also works with your insurance carrier to determine eligibility and coverage for benefits.

Rehabilitation Team: Our experienced rehabilitation team includes physical therapists, occupational therapists, restorative aides, and a speech language therapist.

Pharmacy: Our clinically trained pharmacists are available to advise physicians on the dosages, interactions, and side effects of medications. They can also answer your questions about prescription drugs.
For more information on our Transitional Care Program, call 205-258-4381.

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