When patients are admitted to our Transitional Care Program from the hospital, they are usually told they will only need to be at the “Nursing Home” for a few days or a couple of weeks. We know it is difficult for a patient and their family to accept that they cannot go directly home from the hospital, but it is not realistic to tell every patient they need a few days to recover after an illness severe enough to require a hospital stay. It is very important that we have the ability to articulate the rationale for avoiding a cookie cutter approach to care and ensure the unique needs of each patient and their family are met. At [insert Your Facility Name] Transitional Care, we are experts at providing care and services for patients who have had complications in health status. We have experience which enables us to assess the patient as a team and determine the length of time it will take to get them safely to their next destination. Sometimes this destination is Home, sometimes Assisted Living, and sometimes the patient continues to require the level of care provided only by a Long Term Care Nursing Facility. Our team of professionals will help the patient and their family set and achieve realistic goals and a Safe Transition to their destination. The goal is for the patient to be successful when they go “home” and not have complications that require readmission to the hospital.

Here are some key phrases all staff members can say to patient’s and their families to support the appropriate length of stay for each patient’s Safe Transition. Please note the information provided about Nursing Rehabilitation Services, which is an important component of ensuring a patient is maintaining the skill levels achieved in Physical, Occupational, or Speech Therapy.

• We wish to provide you with the best possible program to assure your Safe Transition to the appropriate destination.
• We know you want to make this Transition with confidence in your skills.
• We know a Safe Transition after the right length of care and treatment in our facility’s Transitional Care Unit will decrease your concern and distress.
• When your therapist discontinues your skilled therapy he/she will Transition you through the Nursing Rehabilitation Program. A Therapist will monitor you as you participate in the Nursing Rehabilitation Program to ensure you are maintaining the level of function you achieved in Therapy.
• As you Transition through the Nursing Rehabilitation Program, you will have the opportunity to practice the functional skills you have regained or achieved in Therapy.
• The Right Length of Stay for you will provide you and those who care about you with an accurate picture of the care you will need when you go home or to another location of choice.
• Our team of experts includes your Physician, a Social Worker, Licensed Nurses, Certified Nursing Assistants, Restorative Nursing Assistants, Therapists who specialize in Physical, Occupational, and Speech Therapy, Recreation Specialists, a Dietitian, and Financial Specialists. This team will help ensure your Transition is successful.
• After you leave our Transitional Care Program, we will contact you weekly for a month, or longer if needed, to ensure your Safe Transition home or other location of choice is successful.

The patient’s Safe Transition date and destination will be posted in a professional manner in their room and their consent for this documented in their medical record. We appreciate all staff supporting the patient and their family by reinforcing their customized Safe Transition Plan.