After being hospitalized at any St. Vincent location in Indiana, our focus goes beyond the hospital care and makes it easy for you move on to the care you need, when and where you need it. This is also referred to as Post-Acute Care services. We know it can be stressful to leave the hospital and wonder how you will do it all on your own. You don’t have to. Our Care Coordinators will explain how your primary care healthcare team will be monitoring you as you heal. With your physician’s recommendation, we’ll also identify the best place for you to continue the healing process.
No matter your age, St. Vincent is part of your continuum of care and recovery. In the U.S., one in five patients require some type of post-acute care service after being discharged from the hospital (Modern Healthcare. June 19, 2017). We offer a wide variety of services to help you stay on your path of wellness, even after you leave the hospital.
In Southwestern Indiana, call the St. Vincent 4Doc Referral Line – 812-485-4362
In Central Indiana, call the St. Vincent CAREline – 317-593-9726
The job of the care coordinator is to work with you and all those who care for you throughout your stay. This professional helps you navigate the continued healthcare services you may need after your hospital stay. The days immediately after being discharged from the hospital is a time of medical vulnerability. It’s important to get necessary rest, follow dietary guidelines, and stay on track with your prescribed medications and therapy schedule. Physical exertion, mental stress and anxiety, financial worries, and social demands can derail the recovery period. These are all causes why patients may relapse and be readmitted to the hospital. We can help you avoid unnecessary re-admission to the hospital.
Throughout the St. Vincent Health statewide network, inpatient rehabilitation facilities (IRFs) are either free-standing acute rehab centers or hospital acute rehabilitation units that provide inpatient physical therapy, occupational therapy and speech therapy for patients with an injury or medical condition that requires intensive daily therapy. As Medicare-certified facilities, each location includes physicians who specialize in physical rehabilitation medicine. They provide daily medical supervision regarding all aspects of care.
As part of the St. Vincent continuum of care, hospital care coordinators and case managers will explain the different levels of post-acute care, including acute rehabilitation. In some cases, a patient may be discharged from a hospital and then during home-based care, realize that an IRF is a better place to get the daily care you need. In these cases, individuals can contact an IRF directly or get a referral from your physician. There are different criteria to be admitted to an IRF, but generally, our patients must be able to participate in at least three hours of intense therapy per day. The average patient length of stay is typically between seven and 21 days. Overall, our acute rehab patient outcomes are better than the national average.
Durable medical equipment (DME) is medically necessary equipment, supplies and accessories as prescribed by your healthcare provider for use at your residence.
DME may include (but is not limited to) bathroom safety equipment, transfer equipment, walking aids and wheelchairs, hospital beds, air-filled mattresses and support surfaces, CPAP devices and accessories, blood sugar monitors and glucose test strips, nebulizers and medication, infusion pumps and supplies, oxygen equipment and accessories, and suction pumps.
Our DME office staff provides reliable equipment in a timely manner, while giving clear instructions for use to the patient and caregiver.
DME is available to patients with Medicaid, Medicare, and commercial health insurance. To learn more about Medicare-approved DME, click here.
Remote Care Monitoring is available through St. Vincent for patients with complex medical conditions. This service allows patients to be monitored in the comfort of their own home using telemonitoring. Patients with remote care monitoring are monitored on a routine basis for the first 45-days after discharging from the hospital or when referred by a primary care or specialty physician.
The case managers in Remote Care Monitoring work to make sure patients have the resources they need to be successful in managing their care. They review education with the patient, provide instructions regarding medications, and connect patients with their provider when needed. The goal of remote care monitoring is to help patients maintain their optimal health and prevent a return visit to the hospital.
Patients cannot self-refer to Remote Care Monitoring. The referral must be made by your hospital team or primary or specialty care provider.
Some patients need more time to heal due to a surgery or complex medical condition. The hospital care coordinator works closely with your care team and may recommend a skilled nursing unit/facility after discharge. At a preferred skilled nursing facility (SNF) or one of our St. Vincent Hospital Swing Bed Units, licensed registered nurses and other team members will provide continued care to you. Services may include complex wound dressings, daily tube feedings, or continuous nursing care and rehabilitation therapies. The short- and long-term care in a skilled nursing facility (also commonly called a nursing home) or swing bed program is more extensive than what is available at home from a caregiver or a home health care provider.
St. Vincent is committed to establishing a strong continuum of care for every patient. If you are a candidate for skilled nursing, ask your hospital care coordinator about preferred locations. St. Vincent has built a network of preferred facilities who have agreed to work with us to implement best practices and ensure we are always working to provide patients with the highest quality and safest care. Our goal is to work together to ensure you continue on the road to better health, so that you can hopefully avoid the need for any further hospitalizations. We are here to help make a smooth transition from hospital to home, wherever that may be.
Skilled Nursing is generally a Medicare benefit if:
Within a hospital, some patients need transitional care before they go home. When you are hospitalized due to a surgical procedure or treatment for a complex medical condition, you receive acute care hospitalization (which can include intensive care). Based on your medical needs and the healing process, some patients may benefit from continued skilled nursing and rehabilitation therapies. One option for this care can be a Swing Bed Program, because you transition (swing) from one level of care to another within the hospital as part of your continuum of care.
The hospital care coordinator will explain this program if it is recommended by your physician as part of your discharge plan. If a local Swing Bed Program is not available, St. Vincent has a preferred network of Skilled Nursing Facilities (SNF) throughout the state of Indiana.
The St. Vincent in-hospital Swing Bed Program helps you improve your overall health and function as quickly as possible. Registered nurses are on staff 24/7 and provide attentive and compassionate care. A provider makes regular visits and gets updates on your progress and medical needs. All rehabilitation therapies (PT or OT) are provided by licensed clinicians (not aides). An in-house pharmacy and registered dietitians are available for your daily medication and dietary needs. If a medical emergency arises, a hospital emergency department is onsite. This program supports your short- and long-term health needs. Our social worker will help you and your family as part of the discharge planning process so that there is a smooth transition to home or wherever you next level of care may be.
At discharge from the hospital, your care coordinator may tell you about an outpatient transitional care or post discharge clinic that is recommended for your initial care immediately after hospitalization. The transitional care team does not take the place of your primary care physician and is offered as part of the St. Vincent Continuum of Care.
During the initial weeks after hospitalization, some patients with complex medical conditions are more medically vulnerable. These specialized clinics are for patients with complex medical conditions such as COPD, heart failure and other cardiovascular diseases, or pneumonia. Additionally, patients who have primary care but have very complex medical needs may be referred to our specialized transitional care clinics as a way to provide focused care and longer visits times. Patients will be referred back to their primary care physician after their complex needs are met. At St. Vincent, our mission is to provide the best post-acute care option, when and where you need it.
The providers on the transitional care team specialize in post-acute care medicine in an outpatient setting, much like the hospitalist specializes in acute care medicine in the hospital. Our goal is to help each patient make a healthy transition from hospital to home and put in place good daily habits to fuel recovery. Our team may also make a recommendation to the patient’s physician regarding other beneficial post-acute care services such as home health care, remote care monitoring, or skilled nursing, if needed.
Patients cannot self-refer to the Transitional Care or Post Discharge Clinics. The referral must be made by your hospital team or primary care provider.