Here’s What to Look for in Transitional Care

You or a loved one has entered the hospital for a planned surgery, such as hip replacement, or an unplanned injury or illness. The hospital is ready to discharge you. But you, and your doctor, feel you’re not quite ready to go back home.

Many adults and seniors find themselves in a challenging situation after a hospital stay, caught in the transitional phase between hospital and going back to their prior living situation in the community, whether it be home, an adult family home, or an assisted living facility. This phase is often referred to as “skilled nursing care,” “rehab stay,” “skilled stay,” or “covered stay,” and involves stay for a time in a specialized unit in a skilled nursing facility. Not all facilities are equal.

Here’s what to look for in a transitional stay

1. Strong clinical staffing and medical oversight
   • Registered nurses (RNs) on duty 24/7. This is critical for patients with complex medical needs.
   • In-house medical director or easy access to physicians. Look for a facility where doctors regularly make rounds.
   • Access to specialists such as wound care nurses, respiratory therapists, or rehabilitation physicians.
2. Physical therapy and rehabilitation services
   • A high-quality facility should have robust rehab services including physical, occupational, and speech therapy available multiple times per week (often daily).
   • Check if therapy is offered on-site and whether sessions are individualized.
   • Ask about equipment and therapy space—ideally a dedicated rehab gyms with up-to-date machines.
3. Clean, safe, and comfortable environment
   • Cleanliness isn’t just aesthetic—it’s a patient safety issue. Look for a facility that smells fresh and appears well-maintained.
   • Private rooms or small shared suites are ideal for infection control and dignity.
   • Check for safety features such as grab bars, call buttons, and non-slip floors.
4. Short-term rehab focus
   • Not all skilled nursing facilities are equal. Some specialize more in long-term custodial care, while others focus on short-term rehab. Make sure the ones you are considering have a dedicated transitional care area.
   • Look for a facility that emphasizes discharge planning and returning patients home as soon as is safely possible.
   • Ask about average length of stay, rehospitalization rates, and success stories.
5. Quality ratings and accreditations
   • Use CMS Care Compare (Medicare.gov) to review:
     • Overall star rating
     • Health inspection results
     • Staffing levels
   • Quality measures specific to short-stay patients.
   • Facilities with Joint Commission accreditation or other independent endorsements often meet higher standards.
6. Personalized care and communication
   • Quality facilities treat patients as individuals, not just diagnoses.
   • Ask about care planning meetings, including how often they happen and who attends (nurses, therapists, social workers, family).
   • Good communication is key. Loved ones should feel welcome, informed, and heard.
   • Smooth transitions in and out.
7. The best facilities have intake coordinators who help make the transition from hospital to rehab seamless.
   • Discharge planning should begin immediately upon admission.
   • Ask if the facility offers post-discharge follow-up or home health referrals.
8. Resident satisfaction and reputation
   • Ask to see satisfaction survey results or testimonials from former patients and families.
   • Visit the facility during busy hours to see how staff interact with patients.
   • Ask about staff turnover rates. A facility with low staff turnover often provides more consistent care.

Health insurance coverage and financial support through Medicare and Medicaid

Dealing with insurance is hardly any patient’s favorite part of any hospital visit. To avoid unexpected expenses and improve the transition process, it can be very beneficial for the patient or family member to call the insurance provider to clarify coverage.

Medicare is set up to pay for skilled nursing and rehab services after a hospital stay, as long as patients meet certain criteria, including having been hospitalized for at least three midnights.

Patients with financial means to buy private insurance and Medicaid patients seeking skilled nursing or long-term care placement will not require a three-night hospital stay. But those who are on a Managed Medicaid plan, such as Apple Care in Washington state, must receive pre-authorization from their plan to qualify for rehabilitation care in a skilled nursing facility (SNF).

Given the complexity of insurance coverage and variations in coverage, patients must understand specific plan policies which can affect the coverage of equipment, medications and the duration of a (TCU) stay. Social workers and case navigators are instrumental in helping navigate these complexities, ensuring informed choices regarding facility transfers.

Depending on the specific plan, equipment and medications may be covered as well. The social worker and your care team are great resources to help you navigate how to successfully clarify Medicare and Medicaid eligibility for your specific case.

Understanding the transition from hospital to a SNF rehab stay can significantly ease stress and anxiety associated with recovery. By being proactive and informed, patients can ensure smoother transition and more effective collaborative recovery plans.

Providence Mount St. Vincent, affectionately known as “The Mount,” is a vibrant living care community for older adults in West Seattle. Maricor Gonzales-Lim, PT, DPT, LNHA, is executive director at Providence Mount St. Vincent. Cynthia Flash, owner of Flash Media Services, represents Providence Mount St. Vincent as a public relations consultant.