Transitional Care

Monument Health’s Transitional Care Program provides skilled nursing care and rehabilitation services for patients who are discharging from the hospital but still need temporary assistance that cannot be provided at home or in a typical skilled nursing facility. The program is designed to assist the patient in becoming as independent as possible before discharge.

Our team of health care professionals will partner with you, your family and the provider to customize your care as you continue to heal. Once you are able to safely discharge, they work with your primary care physician to coordinate any in-home services you may need.

To qualify for the Transitional Care Program, you must meet the following requirements:

• Have had three inpatient overnights in an acute care bed prior to the Transitional Care Program.
• Have an ongoing diagnosis and needs that require skilled care as defined by Medicare.