What is Transitional Care?

Transitional Care is a specialized service for patients no longer needing a traditional acute- care hospital but are not ready to return to home. These patients still require additional skilled medical care, nursing care, or rehabilitation services.

Our team is equipped to care for patients with complex needs, including:

• After Surgery: Cardiac, neuro, orthopedic, abdominal, and more
• Respiratory: Specialized treatment and support of respiratory therapy
• Wound Care: Special attention and skill for wound healing
• Intravenous (I.V) Antibiotics: To treat a variety of infections
• Specialized Therapy: Including physical and speech therapy
• Teaching and Training: Education on management of new procedures or medication management (i.e. new peg placement, newly diagnosed diabetic, new ostomy, heart failure)
• Coordination and Ongoing Assessment of Complex Plans of Care: RN oversight and team collaboration to modify care plans as frequently as patients need

Why Deer Lodge Medical Center?

Our program is supported with evidence – based best practices through a partnership with Allevant Solution developed by Mayo Clinic and Select Medical. Our program is called Transitional care because it is a model focused on healing patients transition from a hospital stay to their highest level of independence at home or in another setting. We use hospital- level resources, team processes, best practices, and extra clinical education to support this “transition.” Since most patients receive this care under Medicare, this level of care is sometimes also referred to as “Swing Bed.”

We provide:

• A personalized plan of care
• Bedside rounds that engage you, your family, and your care team to help you reach your goals
• Hospital-level nursing staff to keep you safe and help you recover
• A home-like environment that accommodates family and participation in activity and rehabilitation
• On-site physicians, therapy, radiology, and laboratory that will address your specific needs

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How do I qualify for Transitional Care?

• Have at least a consecutive three-night qualifying stay as an acute care patient within the last 30 days
• Require a skilled need such as physical therapy, speech therapy, nursing therapy, teaching and training, medication management, observation and assessment
• Medicare A & B; other types of insurances need pre-authorization, but our team can help determine if you qualify under the Medicare guidelines

Outcomes: (January 2018- December 2019)

Average length of stay is 17 days

63% of patients return to home independently

9% of patients were readmitted to an acute facility less than 30 days

4.5 out of 5 people would recommend this program

Patient Success Stories:

Kenny Fleming's TCU Experience

Don Cappa's TCU Experience

For more information, please contact our Transitional Care Nurse Coordinator, Amy Dreesen, RN, BSN

at (406)-846-7730 or akdreesen@dlmed.org