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Transitional Care

Referrals, Admissions or Inquiries

Phone: (831) 385-7211

Fax: (831) 386-7447

Benefits of Transitional Care:

Our hospital-based team offers an effective, local option for recovery with a focus on getting you home or to your next living situation as quickly, effectively, and safely as possible

After a hospitalization for serious illness or surgery, some patients need extended medical care, skilled nursing services and/or rehabilitation to reach their best level of health, wellness, and independence. While the average need is for a week or two of support, some patients benefit from a longer stay.

Often, a hospital-based Transitional Care program is an ideal place to recover, especially for complex medical, nursing, or physical and occupational therapy needs. At Mee, we offer safe, team-based skilled care for those with ongoing needs from licensed nursing or therapy staff to avoid complications, heal more quickly, and increase mobility, strength and independence.

Because of these advantages, patients often choose to recover at Mee Memorial even after a hospital stay in a larger community.

Our capabilities match patient needs

Our goals are to make sure you reach your full potential for recovery, get back to your way of life quickly and safely, and whenever possible, avoid readmission back to the hospital. Some examples of our capabilities include:

  • Nursing assessment and observation of patient needs and outcomes, especially for patients with multiple medical concerns or risks
  • Management and evaluation of complex care plans
  • Intravenous (IV) therapy (antibiotics, pain medication)
  • Rehabilitation and physical therapy after orthopaedic and other surgery, trauma, or fractures (especially severe or complex)
  • Neurological recovery including TIA/stroke
  • Conditioning and strengthening after hospitalization for CHF, COPD, pneumonia, or other chronic conditions
  • Wound therapy
  • Management of respiratory conditions and treatments like high-flow oxygen

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When patients recover in Transitional Care, closer to home, they are often able to leave the acute care setting sooner due to the hospital-based resources, family involvement and buoyed frame of mind.

The MMHS difference

  • On-site hospital services (lab, radiology, x-ray)
  • Flexible, experienced rehab therapy support
  • Trusted teams and low turnover. Many of our staff have been with us for years
  • 2 to 3 times more nursing hours per patient per day than most nursing facilities
  • Immediate physician availability if changes in condition occur
  • Efficient and effective transfer processes to regional hospitals if needed
  • Shorter length of stay: Average 17 days compared to national average of 26.2 days*

*2023 MedPAC Report to Congress, all Medicare Part A Skilled stays in 2021

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Insurance considerations

While patients with Medicare Part A may qualify for up to 100 days of skilled coverage (with co-pay after day 20) if they continue to have a qualifying need, most patients stay around two weeks. Payers other than Medicare Part A may cover a stay in Transitional Care as well. Our team can help determine coverage.

Our program provides a dual-setting option through the availability of our nursing home. Some patients may choose to recover in our nursing home setting due to clinical or non-Medicare Part A insurance policies. Our team works with each patient to place them in the best setting for them considering their personal preference, their clinical needs, and any payer requirements. Some patients find that discharge to the Long Term Care residential setting of our nursing home is the safest and best option after their immediate recovery in the hospital-based Transitional Care program. This is an easy and convenient option when needed.

  • Up to 20 days covered in full (Medicare Part A)
  • Up to 100 days covered with 20% co-payment days 21-100 (Medicare Part A)
  • Medicare supplement may pay deductible
  • Other insurance may also qualify, contact our team to determine
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