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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:

Participate in activities

Perform your own daily care to maintain independence

Dress in your own clothes

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:

This more intimate environment allows the multidisciplinary care team to provide personalized care.

Multidisciplinary teams strive to prepare you for a successful return home, reducing your risk of getting readmitted to an acute care hospital.

You will be able to receive transitional care closer to home which makes it easier for family and friends to participate in your recovery by attending therapy sessions and learning how to help when you go home.

Nurse staffing levels in transitional care match that of the regular hospital setting to ensure you receive all the attention you need.

Patient rooms are well equipped, comfortable and private.

Be seen by a physician every 1-3 days.

Activities

Daily activities:

Communal noontime dining
In-room television
Puzzles
Cards and games
Magazines, newspaper, books
Crossword puzzles, word finds
Wii gaming system

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:

Your own clothing-comfortable clothing such as sweatpants, shorts, button-up shirts, etc.

Personal care items-toothbrush, toothpaste, comb, brush, etc.

Patients are encouraged to bring their own activities, such as craft projects, reading materials, etc.

Any other items that will make your stay more comfortable

Transitional Care Services

24/7 Skilled Nursing Care

Examples of services include wound care, respiratory support, intravenous treatment, pain management and complex tube feedings

Rehabilitation

Rehabilitation services include physical, occupational, speech, and respiratory therapies

Physical Therapy is offered 6 days a week

Occupational Therapy is offered 5 days a week

Speech Therapy is offered 5 days a week

Full Access to Hospital Services

Laboratory, Imaging and other special services are on-site and easily accessible

Social Services

Staff will help find equipment and other resources that might be needed upon returning home

For patients who cannot return home, staff will assist in finding another option for continued care

Activities

Leisure activities are available

How to receive transitional care program services


If you are not a Medicare recipient you must receive prior approval from your insurance company and be referred to the program by your physician.

The patient must also have had a three-day regular hospital inpatient stay within 30 days of admission to transitional care.

Your transitional care stay must be an extension of the condition for which you were hospitalized.

You must require a daily skilled service which has to be ordered by your physician.

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:

Days 1-20: 100%

Days 21-100: There is a daily co-payment that your secondary insurance, or you, are responsible for.

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.

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