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Post-Hospital Care

What Happens After You Leave the Hospital?
Being discharged from the hospital doesn’t mean you are completely well. Many patients need additional services following their hospital stay.

The Deaconess Case Management staff is here to help you make informed decisions about post-hospital care. Our social workers and nurses specialize in connecting patients with available resources and will walk you through your options.

Transitions in Care Program 
What is Transitions in Care? 
The primary goals of Transitions in Care are to ease your transition from the hospital to the skilled nursing facility and to keep you healthier while you are there.

How Does the Program Work? 
Transitions in Care is available at no cost to you. You don’t need to enroll or register—everything happens automatically to enhance and improve your after-hospital care. One of the most important benefits of the program is the Deaconess Clinic nurse practitioner who is available to you. Your Deaconess Clinic nurse practitioner is specially trained to care for older adults and is available five days a week to quickly address any health care needs that may arise while you are in the skilled nursing facility. This immediate access to high-quality Deaconess Clinic care is a key aspect of Transitions in Care.

How Does the Program Benefit Me? 
  • Direct access to a Deaconess Clinic nurse practitioner
  • More involvement in your own plan of care
  • Improved care quality and increased patient safety
  • Improved medication management
  • Patient-centered care
  • Reduced readmission rates and shorter length of stay in the nursing home
Types of Post-Hospital Care
Acute Care
Deaconess Midtown Hospital and Deaconess Gateway Hospital are examples of acute care facilities. Patients in this type of setting are actively ill or injured. The length of hospitalization depends on the severity of a patient's illness or injury. Patients are discharged when medical care can be managed in a less intense setting.

Extended Acute Care
This is a continuation of hospital level care offered by facilities like Select Specialty Hospital. It is available to patients who require medical care that is not available in a skilled care facility. Average length of stay is 25 days.

Rehabilitation Hospital
A rehab hospital, such as the Encompass Health Deaconess Rehabilitation Hospital, offers a continuation of hospital level care. Their focus is on rehabilitation services such as physical therapy, occupational therapy and speech therapy. Average length of stay is 18 days.

Outpatient Rehabilitation
Deaconess Physical Medicine is an outpatient rehabilitation provider offering physical, occupational and speech therapies to help patients after an illness or injury.

Skilled Nursing Home Care
This is a less acute level of care. It is available for patients requiring some skilled medical services (physical therapy, speech therapy, occupational therapy, IV therapy, wound care, etc.) that cannot be given at home. More than one post-acute care provider may be available to serve your needs as prescribed by your physician. Deaconess encourages patients and families to be actively involved in decision making about their continuing health care needs. 

Intermediate Nursing Home Care
This is for patients who require long-term care but don't require the level of care provided by skilled nursing home care.

Hospice Care
Hospice providers offer care to patients who are facing a life-limiting illness and seeking no further curative treatment. Deaconess VNA Home Care and Hospice provides services in the patient's home, in a caregiver's home, in a long-term care facility, or in our inpatient hospice facility. The goal is to control pain and unpleasant symptoms, while providing families with the educational tools and support necessary for quality end-of-life care.

Assisted Living Centers
These facilities typically offer living quarters and meal services for a standard fee. Assisted living services are provided by the facility. Should there be a need for extra services, an outside home health agency, such as Deaconess VNA Home Health Care, can provide those. Examples of both services are below.

Assisted living services include the following:
  • Assistance with bathing
  • Medication monitoring
  • Regular safety checks
  • and more
Home Health Services - while a person stays at an assisted living facility includes:
  • Skilled nursing care 
  • Therapy care
  • Dietician 
  • Assistance with bathing
  • And more
Senior Day Care Centers
These programs offer structured activities for seniors during the day. One meal is typically included.

Home Health Care
Home health care providers offer a variety of skilled nursing, therapy and assisted living services at home. The Deaconess VNA Home Health Care team includes nurses, physical therapists, occupational therapists, speech therapists and social workers. They provide care in the comfort of home with the goal of returning patients to their previous level of health.

Home Medical Equipment
These providers, including Deaconess Home Medical Equipment and Infusion Services, provide durable medical equipment and IV services to patients at home. They offer hospital beds, bedroom accessories, bathroom aids, mobility equipment, respiratory and oxygen supplies, and more.

Deaconess patients may contact the Case Management Department at 812-450-3455 for assistance.
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