Scott Webb (Host): Welcome to Stoughton Health Talk. I'm Scott Webb and today we're going to learn about the transitional care or swing bed program at Stoughton Health from Angela Bakken. She's a Registered Nurse and Nurse Case Manager with Stoughton Health.

Angie, it's nice to have you here today where I'm going to learn here, I think, along with listeners about transitional care and swing bed and what that means, right? So what is transitional care or swing bed?

Angela Bakken, RN: Transitional care and swing bed, the terms can be interchanged. Swing bed is the Medicare term. So swing bed or transitional care is offered at Stoughton Hospital as an effective and great option for patients who need additional therapies or nursing care to recover following a hospitalization.

And typically, their stay is less than two weeks, but there are exceptions. We take Medicare and other insurances for swing bed. So examples of types of swing bed transitional care admissions would be the need to have physical therapy, occupational therapy to get stronger, speech therapy can also be done during swing bed, IV antibiotics that are more than once a day, and another example is complex wound care are things that can occur in swing bed.

Host: Yeah, so it's a matter of semantics really, but as you say, they're kind of used interchangeably , transitional care or swing bed. So then what are the advantages of the transitional care program?

Angela Bakken, RN: I can think of 10 advantages of coming into a swing bed transitional care at Stoughton. We have 24 hours access to medical care, if need be. We have a team of caregivers that establish goals for recovery and a safe return home. These include doctors, nurses, rehab, like physical therapy, occupational therapy, speech, pharmacy, social work, and a dietician.

We have a gift shop here. We have free valet parking service Monday through Friday. We have unrestricted visiting hours, as it's granted there's no pandemic going on. We have private rooms. Cable TV, guest Wi Fi, our food is prepared by our in house chef, so meals are ordered from a menu and are brought to your room.

Visitors may also order from the menu at a nominal fee. And evidence shows that swing bed people tend to recover a little quicker because they get physical therapy usually a little more often, like twice a day. You know, there's always exceptions, but they usually get physical therapy if they need it a couple times a day, except for on Sundays.

So the evidence does show that people do recover a little quicker in swing bed.

Host: Yeah. So lots of advantages, that sounds awesome. So then when folks are there for that type of care, this transitional care, what can they expect during their stay?

Angela Bakken, RN: We typically, the nursing staff will encourage the patient to do as much as they can for themselves to improve their strength, endurance, and independence while they're in swing bed. It is important for them to regain their level of activity and confidence they need to like manage or go back home.

 But we encourage them to bring their own clothes. Good shoes, toiletries, or anything that makes them feel more comfortable. And like I previously said, they do have access to medical care, so if they need that. They have access to pharmacy, good meals. So those are things they can expect.

Host: Yeah, it all sounds wonderful to me. I when we think about having to stay in the hospital and the reasons why someone might be there, maybe, doesn't always bring a smile to somebody's face, but good to know that during this transitional care or swing bed, you know, good things are happening. Good care is being taken of them. So when we think about goals, and the goals you may have for transitional care patients or participants. What are they?

Angela Bakken, RN: Ultimately, the goal is a safe return home is the ultimate goal. So we have short term goals, which are admission day through day seven. And then we have long term goals, which are those for the admission through discharge date. And ultimately, like we said, it's for a safe return home where they feel comfortable to be back in their own home. And isn't that really what we all want is to go back home?

Host: Yeah, I think there's plenty of evidence Angie, out there to suggest that folks just want to be at home, they're more comfortable at home, they definitely seem to recover better at home with all their stuff and pets and family and all that good stuff. And ment, yeah, and you mentioned Medicare earlier. Does Medicare cover transitional care stay?

Angela Bakken, RN: It does. And I do want to interject here too. You talked about pets and things. Pets can come and visit as well when patients are in swing bed. So, if that's important to a patient, a pet can certainly come and visit. We love to see the dogs.

Host: No, that, that brought a huge, that brought a huge smile to my face. That's amazing. I love that.

Angela Bakken, RN: Yeah, it's really part of the healing process. And you asked about Medicare covering swing bed. Yes, it certainly does cover swing bed. But there are admission requirements and some rules with Medicare. You must have been inpatient, been a patient in an acute care hospital or like inpatient status for three days within the last month, last 30 days, and you would have to have some documented needs for the swing bed type of care, you know, maybe IV antibiotics more than once a day, you're too weak to go home, both kind of things.

Medicare will cover 20 days at 100%. But a big but, but that doesn't mean you necessarily get 20 days or need 20 days. For example, if you are improving and you are safe to go home, let's say on day 10, then you would be discharged with a safe plan such as home health or outpatient therapy if you would need it.

If you are not making any progress, your care team would also come up with a safe discharge plan as Medicare will discontinue when you no longer meet criteria for a skilled need. So you have to be willing to participate, making some progress for Medicare to pay. If you aren't making progress, then of course we would come up with a safe discharge plan for you.

 And of course, Stoughton Hospital and Medicare want you to have a safe discharge. We aren't just going to kick you out on the street. We have to make sure that you're going to go wherever you need to go and be safe. If you still need swing bed, let's say on day 21, you're progressing, but you still need more days; medicare then covers at 80%, and then your secondary insurance would cover the 20%. We also accept more than 160 other insurances in swing bed, just they need a prior authorization, which would be submitted by our case management.

Host: Yeah, and you mentioned there Medicare and criteria and those things seem to go hand in hand. Can you go through that a little bit more if you need to just to explain what sort of I's need to be dotted, T's need to be crossed, hoops need to be jumped through, per se, for Medicare to pay?

Angela Bakken, RN: Correct. So for Medicare to pay, you have to show willingness to participate. That doesn't mean if you have a bad day, you can't take a little, little rest. But you have to be willing to participate on a pretty regular basis, and you have to show that you're making progress. It can even be slow progress, but as long as you're making progress, then Medicare will continue to pay.

Host: That's perfect. Just want to give you a chance here at the end. If folks want to learn more or speak with you directly, how can they do that?

Angela Bakken, RN: So if you are in the hospital and feel swing bed transitional care may be what you need, please speak with your social worker and request Stoughton Hospital. The social worker will make the referral. Patient doesn't have to do anything. The goal is for a safe transition return back home. If you have any questions or want a brochure, you can call Stoughton Hospital case management at 608-873-2217 and we will answer your question.

Host: Yeah, that's great. You know, I told you it was sort of prefaced as we got rolling here that I felt like this was going to be educational and it is. Listeners and myself, we now know what transitional care is and that swing bed is a term often used interchangeably. And of course, the goal is to, you know, treat patients well while they're there, get them home as quickly as possible.

Of course, have their pets visit if that's something they choose to do. So it's all good stuff. Thank you so much.

Angela Bakken, RN: You betcha, Scott. Thank you for talking to me.

Host: And for more information, go to stoughtonhealth.com. And that concludes this episode of Stoughton Health Talk. Please remember to subscribe, rate and review this podcast and all the other Stoughton Hospital podcasts. I'm Scott Webb. Stay safe and be well.