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
Three-day hospital stay
A qualifying need, which may include the following:
Hospitalist, Internal MedicineView Profile
