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Rehab to Home

Horizon Health Transitional Care Program

Our Rehab to Home program is for patients who have been treated for an acute condition and still require ongoing skilled care for that condition. While there are a number of types of patients who may benefit from skilled care, probably the most common are those who have just had surgery.

Services and amenities of our Rehab to Home Program include the following:

  • 24-hour nursing care with physician onsite
  • Weekly doctor visits
  • Room service dining
  • Hospital care in a friendly atmosphere
  • Individualized therapy plans
  • Consistent staffing
  • Fully equipped and staffed rehabilitation services department
  • Full-time activity coordinator
  • Private rooms
  • Constant communication with patients and their families before and after admission
  • Covered by most insurances

We Follow Medicare Guidelines

Skilled care is provided by educated, licensed/certified providers in the fields of nursing and physical, occupational, and speech therapy. The program follows Medicare guidelines:

Skilled care needs to occur at least daily. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a skilled nursing facility. The services delivered must be reasonable and necessary for the treatment of the patient’s illness/injury (i.e., services must be consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice). The services must also be reasonable in terms of duration and quantity.

Note that the skilled care does not have to take place at the hospital in which the acute care was performed. Commonly, patients go to a large institution for surgery and then return to their smaller, hometown hospital for their skilled stay.

Discharge Planning

Discharge planning begins at the time of admission. The goal is to make sure you have the help you need when you leave the hospital.

Discharge Planning includes:

  • Coordinated care with physicians, clinicians, and
    other health providers.
  • Facilitated communication among the patient,
    family, doctors, hospitals, insurance companies,
    and other parties.
  • Evaluation of patient progress and revision of
    the care plan if needed.

Criteria for Admission

Contact or Referral:
Bruce Maxwell, BSN, RN, ACM
Case Manager
(217) 466-4749

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