
Transitional Care
Who Needs Transitional Care?
You may benefit from Transitional Care at Pinckneyville Community Hospital if you are recovering from an illness or surgery and no longer need acute care, but you can't return home yet.In transitional care, you receive daily skilled care by a nurse and/or therapists at Pinckneyville Community Hospital. If your condition permits, you will be encouraged to:



Creating a Plan of Care for You
A multidisciplinary team will work with you and your family or other caregivers to develop an individual plan of care. The plan focuses on meeting physical, spiritual and social needs. Team members will meet with you daily to ensure the plan is being carried out.Our Team Approach
Multidisciplinary teams include physicians, nurse practitioners, registered nurses, licensed practical nurses, certified nursing assistants, social services, case management, transitional care nurse, rehabilitation professionals such as physical, occupational, speech and respiratory therapists, pharmacists, dieticians and pastoral care.Preparing for Independence
Here's how you and your family can benefit from the program:





Activities
Daily activities:






Monthly activity calendar posted in patient room and given to each patient upon admission.
Discharge Planning
Case Management, along with the entire multidisciplinary team, physicians, the patient and family, will begin planning for the patient's discharge and post-hospital care immediately upon admission to transitional care. This provides the patient and their family or caregiver the confidence and ability to continue the healthcare needs in their own home, on an outpatient therapy or home health basis or in a nursing home.What is expected of you
All transitional care patients are expected to work with occupational therapists, physical therapists and speech therapists to achieve the goals necessary for a safe and successful discharge home.It is required by Medicare that patients receiving therapy be able to demonstrate significant progress toward their goals to continue to qualify for insurance coverage. Team members will meet with you to ensure plan is being carried out. If you do not show progress toward your goals, other arrangements, such as nursing home placement may be made for your care.
What to bring
Just like a stay away from home, you should bring:



Transitional Care Services
24/7 Skilled Nursing Care
Rehabilitation




Full Access to Hospital Services

Social Services


Activities

How to receive transitional care program services




Case Management will review coverage with the patient and their family prior to transferring to transitional care and will monitor continued eligibility throughout the stay.
How transitional care services are paid for
For Medicare patients:

For other patients:
Refer to your insurance plan benefits.
The patient and their family are involved in the coordination and planning of care with the rehabilitation team. Patients and their families are kept up to date on the patient's status of coverage and when this would cease.