Transitional Care - Skilled Nursing & Rehab Services

There's No Place Like Home!

Sometimes we are not able to return home immediately following a hospitalization. In the case of a hospital visit, we sometimes need time and patience so that when we return home we are better able to care for ourselves.

Regaining Strength to Return Home

At C.A. Dean, we can care for patients who are "not sick enough for a hospital bed" but "too sick to go home." We call this in-between time transitional care (referred to as swing beds or skilled beds within the healthcare field).

Transitional Care patients usually need to stay in the hospital in order to restore function, improve strength, and regain independence for daily living activities, like bathing, dressing, and feeding. Because of this focus, patients are treated more like residents than hospital patients. They may dress in their regular clothes, attend activities, and socialize in the family room. All the while, these individuals are regaining their strength, mobility, and independence to return home via a team of nurses, physicians, rehabilitation therapists, a case manager and an activity coordinator.

Possible Reasons for Transitional Care

Returning home can be premature for any number of medical reasons. In transitional care cases, skilled nursing and/or rehabilitative services are needed on a daily basis. The following are some conditions that would require this type of care:
  • Head injury
  • Pain management
  • Reconditioning after a lengthy hospital stay
  • Recovery from an accident, injury, illness or surgery (hip replacement, knee replacement, back surgery)
  • Stroke
  • Wound care

Guidelines for Transitional Care Patients

A transitional care (or swing) bed is a designation for hospital beds that can serve either transitional care or acute care patients. To a patient, the switch from one level of care to another is often transparent. The change is done on paper and the patient doesn't even have to move to a different room or bed. In order to be eligible as a transitional care patient, the person must meet criteria set by your insurance company. C.A. Dean's Case Manager will assist you with eligibility and prior authorization if needed. Generally patients must meet the following criteria:

  • Patient has three overnights in an acute care bed
  • Services require the care of a skilled professional

Patient requires skilled nursing or rehab services on a daily basis as ordered by a physician. Services received in transitional care may include:

  • Education (e.g., disease process, use of prosthetic devices, medication use)
  • Intramuscular injections
  • Intravenous medication
  • Nursing care
  • Nutritional therapy
  • Occupational therapy
  • Physical therapy
  • Wound care

Services are provided with the expectation that the patient can improve within a reasonable and generally predictable timeframe and return home.

Preparing for Transitional Care

A healthcare provider usually discusses the transitional care option with eligible patients sometime during a hospital visit or before coming to the hospital (e.g., elective surgery). After the decision is made, paperwork is completed for the transitional care stay. The patient generally does not need to move to a different room or bed, unless transferring from another facility. A team of healthcare professionals will coordinate your plan of care. This team of professionals will meet weekly to discuss with you and your family a continued care plan as well as strategies for the return home.

Choosing C.A. Dean for Extended Nursing & Rehab Care

At C.A. Dean, our low patient to nurse ratio and commitment to patient and family member satisfaction enable us to provide high quality care. Our competent nursing and rehab staff are part of a well-connected treatment team. We personalize each patient's care with compassion and dignity.

We know that there is no place like home. That's why patient care is our number one priority.

Care That's Closer to Home

We welcome an opportunity to talk about our Transitional Care Program. Please call 207/695-5200 and ask to speak with a Transitional Care Program Representative.

Download our current Transitional Care brochure