Services Transitional Care

Transitional Care

Regional 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.

Home+ Home Care

  • Provided in the comfort of your home
  • Multidisciplinary team approach to care
  • 24/7 availability to registered nurse to answer questions
  • Case management for chronic health problems
  • Intermittent nursing visits scheduled to meet your needs
  • Therapy visits scheduled to meet your needs

Nursing Home

  • Private and semi-private rooms
  • Provider access 3 days a week
  • Average length of stay 23-48 days
  • Multidisciplinary team approach to care*
  • Therapy 6 days a week

Hospital-Based Transitional Care

  • Private room
  • Provider visit at least every 7 days with 24/7 availability
  • Average length of stay 13-15 days
  • Multidisciplinary team approach to care*
  • Therapy available 5 days per week
  • Nurse ratio: 1 nurse for every 4-5 patients

Hospital-Based Rehabilitation

  • Private room
  • *Minimum of 3 face-to-face visits by provider per week
  • Average length of stay 12-14 days
  • Multidisciplinary team approach to care*
  • Therapy available 7 days per week
  • Nurse ratio: 1 nurse for every 5-6 patients

Criteria

  • Within Home+ Home Care service area
  • No prior hospitalization required
  • Skilled care such as IV antibiotics, wound care, therapy needs
  • Medicare and most insurances pay 100%, Pre-authorization provided
  • Leaving the home may be difficult
  • Can accommodate multiple conditions
  • Short or long term stay

Criteria

  • *3 day hospital stay
  • Able to participate and progress with therapies
  • Skilled care such as IV antibiotics, wound care, therapy needs
  • Can accommodate multiple medical conditions
  • Short or long term stay

Criteria

  • *3 day hospital stay
  • Able to participate and progress with therapies
  • Skilled care such as IV antibiotics, wound care, therapy needs
  • Can accommodate multiple medical conditions
  • Short term stay

Criteria

  • 3 day stay not required
  • *Medically able to tolerate and participate in three (3) hours of multidisciplinary therapy per day and have the potential to significantly improve
  • *Skilled care such as IV antibiotics, wound care, medically complex care and at least two disciplines of therapy needed
  • *Have a qualifying rehabilitation diagnosis – primary focus on 13 medical conditions
  • Short term stay

*based on Centers for Medicare and Medicaid Services, some insurances may differ

 

The following Regional Health hospitals operate a Transitional Care Program:

  • Custer Hospital 1220 Montgomery St. Custer, SD 57730 – 605-673-9400
  • Lead-Deadwood Hospital 61 Charles St. Deadwood, SD 57732 – 605-717-6000
  • Sturgis Hospital 2140 Junction Ave. Sturgis, SD 57785 – 605-720-2400