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Transitional Care

CCM Health - General / Primary Care

Personalized Care from Hospital to Home

CCM Health offers discharge planning and Transitional Care to all in-patients. Only your doctor can authorize your release from the hospital, but the actual discharge process will begin early on in your admission to the hospital. The discharge planner will meet with you and you loved ones to determine what you need to make a smooth transition from one level of care to the next. You will be provided with a Patient Health Folder which will contain the Discharge Checklist to assist you in making sure all of your questions have been answered prior to discharge.

The discharge planner will make referrals as needed to community resources including:

  • Skilled Nursing Facilities
  • Skilled Swing Bed
  • Assisted Living
  • Home Health Care
  • Adult Day Services
  • Durable Medical Equipment
  • Social Services
  • Financial Services
  • Housing
  • Meals on Wheels
  • Transportation Resources

Two Types of Transitional Care

Skilled Swing Bed

If you are being discharged from the hospital, but you still require medical care, including around-the-clock nursing care services, you may be able to benefit from our hospital’s Swing Bed Program. This program is designed to provide the type of assistance that recovering patients need when they are transitioning from the hospital to their home.

Individuals who are transitioning from the hospital to a nursing home facility may also benefit from our Swing Bed program.

This type of care is administered when a recovering patient still needs daily skilled nursing or rehabilitation services. The patient is well enough to leave the hospital, but he or she still needs a professional, licensed medical caregiver to perform tasks such as wound care, catheter care, or physical therapy.

The Swing Bed Program helps provide transitional care to patients recovering from a hospital stay that are not yet ready to return home. When you need daily skilled nursing care or skilled rehabilitation services, you may be eligible for Skilled Swing Bed.


  • Recovery from major surgery or joint replacement.
  • Recovery from a major accident or stroke.
  • Pain management
  • Complex wound care
  • IV therapy
  • Rehabilitation therapy: physical therapy, occupational therapy, speech or respiratory therapy


Medicare will cover skilled swing bed if:

  • You have Medicare Part A and have days left in your benefit available to use.
  • You have a consecutive, three-day, acute in-patient hospitalization prior to skilled swing bed care.
  • Your doctor has determined you need daily skilled care. Care must be provided directly or under the supervision of skilled nurses or therapists.
  • Commercial Insurance requires prior authorization for skilled swing bed and typically follows Medicare criteria.

The Swing Bed patient remains in the same private hospital room but benefits from fewer interruptions while still receiving the therapies and cares their doctor has ordered. The Swing Bed Program gives patients the extra time to heal in familiar surroundings, close to home.

Respite Care

A recovering patient may need respite care when he or she requires custodial or maintenance types of care. For example, respite care may include helping the patient get dressed or helping the patient take a bath. Respite Care is available for patients that require short-term maintenance or custodial care. Respite is typically a non-covered level of care. Payment arrangements can be made through the hospital business office.

For additional information contact the hospital care manager at (320) 321-8480.

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