Transitional Care

Key Features Include:

• A personalized plan of care.
  
• Bedside Rounds that engage you, your family and your care team to help you reach your goals.
  
• Hospital level nurse staffing to keep you safe and meet your needs.
  
• Promotes a home-like environment accommodating family and individualized activity programs, as well as therapy in several environments.
  
• Our on-site physician, therapy, radiology, laboratory and pharmacy teams will address all your medical needs.

Western Wisconsin Health is a full service community hospital. We offer a wide range of services, including a high-quality Transitional Care program.

Transitional Care supports patients recovering from an acute illness or surgery who no longer require acute hospital care but are not yet ready to go home.

Our Transitional Care program allows you to continue to receive the medical services and full care team support you need, while working to increase your ability to perform as many of your normal tasks as you normally would. While in our Transitional Care program, you will be encouraged to dress, bathe, and function much as you would at home.

The Transitional Care team will work with you and your family to adjust the care plan as you progress. Stays in hospital-based Transitional Care programs are often much shorter than in other post-acute facilities. Transitional Care is a defined benefit for Medicare Part A covered patients under the Swing Bed reimbursement option. Other insurances may cover the program as well with prior authorization.

Patients in the Transitional Care Program must meet certain criteria, including daily nursing or therapy interventions, teaching and training, or coordination and assessment of complex care plans.

Some examples include:

• After Complex Surgery
  Cardiac, neuro, orthopedic, abdominal and more
  
• Respiratory Needs
  Specialized treatments and support
  
• Wound Care
  Special attention for wound healing
  
• Intravenous (I.V.) Antibiotics
  To treat a variety of infections
  
• Specialized Therapy
  Including physical therapy and an array of supportive services

Meals 

While in Transitional Care, you will be provided with an expanded menu of freshly prepared meals from our Eatery. Our dietician will help you design meals based on physician’s orders and your food preferences. You will be given a daily menu from which you can make your food selections.

Activities

We want your stay to be as pleasant as possible, and our Occupational Therapy Department will assist you with activities that meet your needs and interests while you are here.

Temporary Leaves

If you wish to leave the hospital for a few hours and your condition allows, we will be happy to assist in obtaining an order from your physician. Temporary passes may be used for outings such as a short visit home or an activity of your choosing.

Visitors

We encourage your family and friends to visit with you while you are in Transitional Care. Children under 14 are welcome with adult supervision. We ask that visitors not enter the hospital if they have a cold, sore throat or any other contagious illness. Inquire with nursing staff regarding available visiting areas.

The rehab team at WWH offers the following services during transitional care:

• Individualized programs tailored to each patient’s needs and discharge goals.
• Home assessments recommended to ensure patient is ready to return home and to target specific functional needs in therapy prior to discharge.
• Family/caregiver education and training to ensure both patient and caregivers are safe with the return home.
• Evidence-based interventions to help people improve across all areas, improve their quality of life, and avoid further injury.
• Therapy does not just occur in rehab sessions. Rehab participants will be given exercises to complete outside of therapy and are expected to perform at the same level with nursing staff as well.

Rehab as primary qualifier

• You will be seen twice a day by PT and OT and possibly once over the weekend.
• Initial length of time for treatment sessions will be based on your evaluation.
• Our expectation is that patients progress towards 60 min treatment sessions.

Rehab as secondary service

• You will be seen twice a week by PT and OT, not on weekends.
• You will be expected to do exercises on your own as well as walking with nursing as requested in between therapy appointments.
• Length of sessions will be based on all medical factors in addition to physical needs.

Rehab consultations

We will provide consultations and home assessments on all swing bed patients as requested even if rehab is not a primary need.  We will work with the nursing team to develop a program to maintain strength and endurance within what their medical diagnosis allows. We also provide recommendations as to the level of independence patients.

Click here to review the full list of transitional care rehab expectations

Physical Therapy

• Our PT team provides services ranging from orthopedic care, geriatric rehabilitation, neurological rehabilitation, and post-surgical recovery.
• Our team is equipped to address a high number of conditions and diagnoses safely and effectively in our rehab department, fitness center, and therapeutic pool.  We also utilize the hospital grounds when able to simulate return to independence for staff.

WWH physical therapists:
Ben Wunrow
Deb Kramer
Jayne Rimer
Jen Jorgensen
Jen Hinkel
Luke Grosskruetz

Occupational Therapy

• Our OT team helps people increase their independence in important daily activities and roles.
• Our OTs address a variety of areas including home safety assessments, daily activity deficits, cognitive impairments, conditions of the elbow/wrist/hand, and neurological vision deficits.
• Lymphedema management services are also available through our OT department.

WWH occupational therapists:
Emily Eckberg

Speech Therapy

• Our skilled SLP team addresses a variety of language, communication, swallowing, and speech impairments.
• WWH offers video swallow study evaluations and bed-side assessment for tracking progression through the therapy process.
• The SLP team works closely with our OT team to progress all areas of cognition as well.

WWH speech therapist:
Adam VanRanst

During your stay at Western Wisconsin Health, we ask that you bring the following items with you to help us provide the best care possible:

• Several changes of clothing as there is not a laundry service available.
  
• Comfortable shoes.
  
• Any personal equipment you use regularly such as a cane, walker, etc.
  
• Any special personal care items you use at home; we provide a standard set of products, however, you may have your favorites that you’d prefer.
  
• Any items that would contribute to your comfort while you are here such as a pillow, blanket or family photo.