Facilitating the Transition Between Hospital and Home

Recovering from orthopedic, cardiac or neurologic conditions or surgical procedures can mean a long journey of inpatient rehabilitation to re-learn how to function independently. For many, the inpatient recovery process leads to a Skilled Nursing Facility (SNF) where patients receive rehabilitation services and the education they need prior to returning home.

SNFs Provide:

• Transitional step between a hospital stay, another level of care, or home.
  
• Rehabilitation program for patients who do not have the endurance to participate in, or require the intensity of, an acute rehabilitation program.
  
• Plan of care focused on stabilizing patients following acute illness or injury.

The Role of the Skilled Nursing Facility
At Alta Bates Summit Medical Center, we understand the critical role of the SNF in the rehabilitation process, and we offer a full complement of interdisciplinary services at our hospital-based SNF at the Summit Campus. Services include:

• 24-hour, skilled-nursing care
  
• Physical therapy
  
• Occupational therapy
  
• Speech therapy
  
• Respiratory therapy
  
• Recreational/activity therapy
  
• Social services
  
• Dietary services
  
• Chaplaincy

Individualized Care Plans
Working in the care continuum, we coordinate with staff at the patient’s previous level of care to fully understand the patient’s circumstances and needs. We then develop an individualized care plan for that patient. Each patient’s team of providers coordinates care among all services to help the patient reach his or her discharge goals.

Family and Caregiver Training
We also provide on-going, individualized family and caregiver training to help prepare the patient following discharge. Instruction in safety, therapy techniques, medication usage, skin care, home environment safety, disease process, and accessing community resources are an integral part of the family’s preparation. Our social services team is available to support the family in planning and transitional placement with community agencies, if needed.