Health care services for patients in transitional care units and nursing homes
Health care needs aren’t limited to a clinic or hospital setting. SeniorCare Transitions helps patients who need medical care in transitional care units (short-term care facilities) and nursing homes (long-term care facilities). We work with patients and their families to provide routine care, manage medical problems, monitor rehabilitation and plan for discharge.
We provide medical care at the nursing home, including routine health care, management of chronic illness (such as diabetes), care of acute illness (such as pneumonia), medication management, advance care planning and end-of-life care, when necessary.
Our goal is to provide skilled rehabilitative care, as part of your continued care, after your hospital stay. We help you work to overcome “barriers to discharge” to provide a safe transition to home or other suitable living arrangement.
We staff each transitional care unit with an experienced nurse practitioner who will see patients twice weekly. A doctor makes scheduled visits weekly and works with the nurse practitioner by phone at other times. Allina SeniorCare Transitions teams are on call 24/7.
In the nursing home, the nurse practitioner provides primary care including:
routine health care, management of chronic illness (such as diabetes), care of acute illness (such as pneumonia), medication management, advance care planning, and end-of-life care, when necessary.
The doctor on your care team rounds with the nurse practitioner on a regular basis and is available at all times for consultation. Allina SeniorCare Transitions teams are on call 24/7.
SeniorCare Transitions considers a number of things when deciding which locations we will provide care. These include the location, reputation, average number of beds available for patients, number of patients who are discharged to home rather than readmitted to the hospital, availability of therapy staff and the number of clinicians and doctors we have available to care for patients.
The services provided by SeniorCare Transitions are billed to your insurance company. We will submit a claim for services to your insurance company on your behalf. Please contact your insurance carrier directly for questions about your insurance benefits.