Transitional Care Program

What is Transitional Care?

Transitional Care is for patients who are ready to be discharged from a traditional acute-care hospital but aren't quite ready to go home. These patients still require additional skilled medical care, nursing care, or rehabilitation services.

Why is the program called “Transitional Care” and is it the same as “Swing Bed”?

• Our program is called Transitional Care because it is a model focused on helping patients transition from a hospital stay to their highest level of independence at home or in another setting. We use hospital-level resources, team processes, best practices, and extra clinical education to support this “transition”. Since most patients receive this care under Medicare, this level of care is sometimes also referred to as “Swing Bed.”

Admission Inquiries

• Kim Barnett MSN, RN
• RN Case Manager
• Phone: (806) 998-4533 extension 353
• Fax: (806) 516-9964(until I get e-fax)
• Email: kimbarnett@lchdhealthcare.org

Our team is equipped to care for patients with complex needs, including:

• After Surgery: Cardiac, neuro, orthopedic, abdominal, and more
• Respiratory: Specialized treatment and support
• Wound Care: Special attention for wound healing
• Intravenous (IV) Antibiotics: To treat a variety of infections
• Specialized Therapy: Including physical therapy, occupational therapy, and speech therapy
• Teaching and Training: Education on management of new complex conditions
• Coordination and Ongoing Assessment of Complex Plans of Care: RN oversight and team collaboration to modify care plans as frequently as patients need

Why Lynn County Hospital District?

We provide:

• 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 help you recover
• A home-like environment that accommodates family and participation in activity and rehabilitation
• On-site providers, therapy, radiology, laboratory, and pharmacy that will address your specific needs

Our Transitional Care Program is centered on teamwork, communication, and collaboration. Your care team will work with you and your loved ones on a personalized plan, support your goals, and meet with you on a regular basis to celebrate successes and adjust the plan.

Transitional Care News

• Did you know our hospital was just awarded Top 20 for Best Practice in Patient Satisfaction for 2023 for ALL of the nation! Check this out: Patient Satisfaction Award

Frequently Asked Questions

• How long do patients typically stay in Transitional Care?
• Most stays in Transitional Care are a few days to a few weeks, however, some patients may stay for up to 100 days if they have daily qualifying skilled care needs. The majority of patients in our program improve their health and rehabilitation status during their stay, and the majority of program patients who lived at home prior to their hospitalization are discharged back home after Transitional Care.

Is Transitional Care covered by my insurance plan?

• Transitional Care is predominantly covered by the Medicare “Swing Bed” benefit. Some other insurance providers may cover this care as well. If you are having a planned hospitalization and think you might need care after your stay, we can check if Transitional Care would be covered so you can plan ahead of time to come to our programs.

How is Transitional Care different from the care received at a Skilled Nursing Facility or nursing home?

• Because we are a hospital, we can deliver Transitional Care with high levels of safety, quality, and flexibility with hospital-based resources including on-site lab, radiology, and immediate access to physicians and other caregivers. Our hospital-based Transitional Care program provides up to 2 - 3 times more available nurse hours per patient day compared to most skilled nursing facilities. We hold Bedside Rounds with patients, family, and care team together on a scheduled basis, so everyone understands your plan of care, identifies things that need to be addressed, and plans for a safe discharge.

Transitional Care Outcomes

Transitional Care Average Length of Stay: 14 Days (87 patients discharged)

This is the mean average length of Transitional Care patient stays at Lynn County Healthcare System for patients whose last day of Transitional Care was between October 2022 to June 2023. This is calculated by adding the number of days patients stayed in Transitional Care divided by the number of patients whose last day of Transitional Care is within the date range. The calculation includes all dispositions (home, assisted living, end of life, etc.) The calculation does not include the day of discharge.

Discharge to Acute Care During Transitional Care Stay Equal to or Less than 30 Days: 6% (of 87 discharges)

This measure describes the percentage of Lynn County Healthcare System Transitional Care patients who were discharged directly back to an acute care hospital inpatient bed during a Transitional Care stay of 30 days or less. The return to an acute care hospital bed may be for any reason (for example, a medical procedure planned prior to the Transitional Care admission, or unplanned, if medical needs change during the stay). The denominator includes all patients whose last day of Transitional Care is within the date range of October 2022 to June 2023.

Return to Independence: 80% (of 87 patients)

Describes the percentage of Lynn County Healthcare System Transitional Care patients who lived at home or assisted living prior to their Transitional Care stay who were then discharged back to home or assisted living from Transitional Care. This only includes patients admitted with a prior living situation of home or assisted living whose last day of Transitional Care was within the date range of October 2022 to June 2023.

Meet Our Team

• CEO – Melanie Richburg DNP, FNPC, RHCEOC
• CNO – Tonya Price MSN, RN
• RN Case Manager – Kim Barnett MSN, RN
• Transitional Care Occupational Therapist – Shelbye Omondi OT
• Transitional Care Physical Therapist – Savannah McMillen PT, DPT