Transitional Care

Transitional Care Program: Bridging the Patient from Hospital to Home

At Community Hospital of Staunton, we understand there are times when a patient no longer needs the acute care they receive in the hospital, yet they may not feel strong enough to return home. For those patients, we offer a comforting alternative – our Transitional Care Program, commonly referred to as “swing bed care.” (Swing bed care is the term that Medicare uses for a room of the hospital where a patient’s level of care can alternate from acute care status to skilled care status.)

Our Transitional Care Program is designed to provide patients with individualized, in-hospital care and physical rehabilitation to help them reach an optimal level of functioning. This post-acute care is designed specifically for patients who are discharging from acute care but need temporary additional care that cannot be provided at home or in a long-term care facility.

Swing bed care utilizes a combination of first rate rehabilitative therapies, attentive nursing care, and medical supervision to help patients gain the strength, functionality, balance, and range of motion they need to care for themselves with confidence before they return to their own homes.

Who Qualifies for Swing Bed Care?

The types of patients that commonly receive swing bed care include:
Individuals who recently underwent an orthopedic surgery, such as a hip or knee replacement.
Someone who endured a serious fracture.
An individual who recently suffered from a stroke or other neurological disorders.
Acute stay patient whose illness has left them weak and debilitated and therefore require some form of rehabilitation services to return to normal functioning.

You’ll find that Medicare and most insurance companies cover swing bed care services. These services are usually covered under the “Skilled Nursing Facility” benefit category. Medicare and state regulations provide the following patient eligibility guidelines:

A patient must be hospitalized as an “acute care inpatient” (not an “observation patient”) for a minimum of three consecutive midnights within a 30-day period.
Admissions can come from any hospital, including our hospital, after three consecutive midnights as an inpatient in acute care.
A physician referral is required. You or your family can request that your social worker or discharge planner refers you to our Transitional Care Program.

How Long Does a Patient Stay in the Transitional Care Program?

The duration of a patient’s stay at the hospital in our program depends on his or her medical needs and progress. While the average stay is between 7 to 14 days depending on the skilled need and the patient’s progress. An individual will be discharged when the physician has cleared him or her. It is important to remember that swing bed care is never meant to be permanent and is only utilized for continued care until the patient is ready to return home or is transferred to another healthcare facility.

For more information, please contact our Case Management Department at 618-635-2200.