Transitional Care: The Best Place to Heal

By Veena Madiraju

For some of us, a hospital stay is no big deal. We go in, we get treated, we go home.

As we age, however, the process may not be that simple. Our bodies don’t recover as quickly, we need more help getting back to normal, and we’re at greater risk of something happening that will send us back to the hospital.

To reduce that risk there’s transitional care, which helps people make the transition from hospital to home. The goal is to get you back to your pre-hospital level of functioning and ensure you can return home and resume your daily activities safely.

At St. Ann’s, we do that by providing short-term, 24-hour care and rehabilitation services that include physical, occupational and speech-language therapy.

Of course, everyone wants to go home ASAP. But a short stay in rehab will ensure you are fully recovered and able to do everything you did before you entered the hospital. In fact, at the Transitional Care Center at St. Ann’s, the first thing we do when you arrive is make a plan to ensure your safe discharge—setting goals for improvement while you’re with us and outlining what needs to happen once you go home.

Discharge planning is coordinated by an interdisciplinary team that includes doctors, nurses, therapists, social workers, dietitians and case managers. Together they will outline the steps, responsibilities and timelines for your care and discharge. In addition to your personalized rehab goals, this includes education and training for you and your support network on topics such as medication management, self-care techniques, fall prevention strategies, dietary guidelines, coping skills and follow-up care. It’s all part of our goal of getting you back to full strength.

It’s important to consider the impact of major surgery on our bodies, especially as we age. Our ability to do things we take for granted when we’re in good health — getting up from a sitting position, walking across a room, getting in and out of a car — can be seriously impaired. A fall or other setback can make matters worse, delaying your recovery.

You may have family or friends willing to look in on you, but they can’t provide the round-the-clock skilled nursing care the staff at a transitional care center can. Simply put, it’s the best place to heal. And you’ll leave with sound, medically approved strategies to continue your recovery at home.

Although the hospital may make recommendations, the choice of where to go for rehab is entirely up to you. Look for someplace that offers the “three P’s”:

• Personalized care. Therapy should be individualized to meet your specific needs.

• Partnership. Staff engage you and your family in decisions regarding your care.

• Proactive. The care team is able to foresee potential health problems and address them before they occur.

An important tip

Once your surgery is scheduled, do your homework. Look into the options for transitional care — contact the admissions office and find out what they offer. Once you’ve made a decision, pre-plan your stay. When you’re ready to leave the hospital, it’s one less thing to worry about. You’ll be glad you did!

Veena Madiraju is assistant administrator of the Transitional Care Center at St. Ann’s Community. She can be reached at