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Transitional Care

Advanced Nursing Care & Extended Physical Rehabilitation Services

Valley Health’s Transitional Care program, more commonly known as a “swing bed program,” offers comprehensive short-term post-acute rehabilitation services. These services include skilled nursing, physical therapy, occupational therapy, and speech therapy; along with other services that are normally provided in a hospital.

The goal of transitional care is to help patients focus on increasing independence and quality of life to seamlessly move from acute hospitalization to the next level of care. Most commonly, patients who benefit from transitional care include:

  • Neurologic- stroke, Parkinson’s disease
  • Orthopedic- total joint replacement, compound fractures, hip fracture, spinal surgery
  • Cardiac- heart attack, open-heart surgery, congestive heart failure
  • Pulmonary - chronic obstructive pulmonary disease, pneumonia
  • Medically complex conditions
  • Weakness after an extended hospitalization resulting in an inability to care for yourself at home

Who Pays for Transitional Care?

In general, Medicare Part A will pay for Transitional Care if a patient meets the following criteria:

  • The visit must be linked to an acute 3-night hospital stay in the last 30 days
  • The patient must require inpatient skilled nursing or therapy services on a daily basis under the supervision of healthcare professionals.

Medicare will cover the first 20 days at 100% with a co-pay required for additional service days as needed. Many commercial insurances, as well as, Medicare HMOs, also offer transitional care (swing bed) benefit, which would need to be verified by the hospital prior to admission to a Valley Health Transitional Care program.

How Long Can I Stay In a Transitional Care Program?

A patient can stay in a Valley Health Transitional Care program as long as they are making clinically meaningful progress as determined by the interdisciplinary care team in conjunction with the insurance benefit guidelines. The average length of stay for a transitional care patient at Valley Health is 8-14 days. Upon completion, patients will be discharged to one of the following:

  • Home with no follow-up services
  • Home with home health for nursing and/or rehabilitation services
  • Home with an order for outpatient rehabilitation services
  • Assisted living facility
  • Skilled nursing or long term care facility
  • Home with hospice


For the safety of our patients, visitors, staff and the broader community, visitation hours may vary. Please click here for the most current visitation guidelines.

How Do I Find Out More Information?

For assistance requesting admission to a Valley Health Transitional Care Program, please contact the hospital nearest you:

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