Transitional Care

Recovery after surgery, an injury or an acute illness is a process. Your care at a Mayo Clinic Health System hospital does not end when recovery begins.

Transitional care, also referred to as post-acute care or a swing bed program, offers a safe transition between an acute care setting and home. You receive Mayo Clinic care in a community hospital setting, keeping you closer to home, family and friends. Your post-acute care team provides skilled nursing, rehabilitation and supportive services to prepare you for a successful return home.

Find out more about transitional care services:

• Conditions and consultations
• Services
• Transitional care specialists
• Referrals
• FAQ
• Transitional care locations near you

Conditions and consultations

A swing bed program reduces the risk of readmission to a hospital. You and your family actively work with a team of caregivers to create a care plan that addresses your medical, spiritual and social needs. Your healthcare team meets with you weekly to ensure you are progressing toward your planned goals.

A care team may recommend post-acute care after a serious health event, including:

• Complications from chronic disease
• Fracture
• Heart attack
• Severe infection
• Serious illness
• Stroke
• Surgery
• Traumatic injury

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Services

Transitional care provides 24/7 skilled nursing care, including:

• Complex wound care
• Cardiac monitoring
• IV treatment
• Pain management
• Respiratory support
• Physical, occupational and speech therapy services
• Tube feedings

You will also have full access to:

• Hospital services, including laboratory and imaging services
• Rehabilitation therapy programs
• Ongoing discharge planning services

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Transitional care specialists

A multidisciplinary team provides transitional care personalized to your needs.

Your daily care team may include:

• Hospitalists and specialists
• Advanced care providers
• Nurses
• Social workers, case managers or both

Additional care and services may be provided by:

• Chaplains
• Occupational therapists
• Pharmacists
• Physical medicine and rehabilitation physicians (physiatrists)
• Physical therapists
• Registered dietitians
• Respiratory therapists
• Speech-language therapists

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Referrals

A referral may be required for transitional care. Call your preferred transitional care location to learn more.

If you are a provider, you can refer a patient online, by phone or by fax.

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FAQ

How is a swing bed program different from an acute care setting?

Transitional care offers standard hospital services. However, your transitional care team helps you to be more independent as your recovery progresses.

You will be encouraged to:

• Participate in daily activities
• Perform daily self-care
• Dress in your own clothes

Patient rooms are well-equipped and comfortable, with private rooms at all locations. You also have access to leisure activities and spiritual programs for whole-person care.

What happens when I transition out of post-acute care?

Our discharge planning team works with you to develop a safe discharge plan. The team helps you identify community resources and ongoing support.

Before you leave, your caregivers are encouraged to attend therapy sessions and learn how to help you when you return home. If you are unable to return home, the transitional care team assists you in finding another option for continued care.

What are my payment options, and do you offer financial assistance?

Our Patient Account Services team is here to help you navigate billing and insurance. Your insurance provider can review coverage details for transitional care.

We serve patients in difficult financial circumstances. We offer financial help to people with an established need and who require medically necessary services.

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Explore locations near you for details on transitional care: