Transitional Care
Bridging the gap from hospital to home
EXAMPLES OF HEALTHCARE NEEDS THAT FREQUENTLY REQUIRE
EXAMPLES OF HEALTHCARE NEEDS THAT FREQUENTLY REQUIRE
Transitional Care:
Our transitional care program offers:
- In-room telephones
- Post-discharge follow-up
- In-room or community dining
- In-room TVs with cable service
- Comprehensive patient and family education
- Beautifully appointed family areas and patient rooms
- 24-hour coverage by nurses specially trained in patient assessment and evaluation
- Large, spacious rehab gyms well-equipped with state-of-the-art medical and therapy equipment
- Rehabilitation services including physical, occupational and speech-language pathology therapies six days a week
- Supervision by experienced physicians, other healthcare professionals and medical staff well versed in post-acute care
- Access to highly trained physician assistants Monday through Friday who works closely with the medical team to provide personalized care.
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Transitional care is a set of actions designed to ensure coordination and continuity when a patient moves between different care settings.
This includes planned handoffs from hospitals to rehab centers, skilled nursing facilities, or home health services to prevent gaps in treatment.
Summary: Transitional care bridges the gap between acute and post-acute settings to maintain continuous, safe patient care.
A multidisciplinary team—including physicians, nurses, social workers, physical/occupational/speech therapists, and pharmacists—oversees patient care.
Physician assistants and other specialists collaborate with this core team Monday through Friday to ensure personalized, evidence-based treatment plans.
Summary: Your recovery is guided by a coordinated team of medical and therapy professionals focused on optimal outcomes.
Patients leaving the hospital after surgery or serious illness who need extra medical and rehabilitative support before returning home are eligible.
Common qualifying conditions include joint replacement, heart disease, stroke rehabilitation, wound care, pulmonary illnesses (like pneumonia), and specialized IV therapies.
Summary: Any patient needing structured medical and therapy services post-discharge can enter Cibolo Creek’s transitional care program.
Transitional care suits anyone experiencing pain, stress, or functional decline after a hospital stay or medical procedure.
It’s ideal for those recovering from illnesses like cancer, congestive heart failure, multiple sclerosis, or after falls and surgeries that affect daily living activities.
Summary: If you need extra medical support and therapies to regain independence post-discharge, transitional care is appropriate.
Most patients stay in transitional care for less than 30 days under individualized care plans.
Length of stay depends on each person’s recovery progress, therapy goals, and discharge readiness, with the aim to return home safely and efficiently.
Summary: Transitional care averages under 30 days, tailored to meet each patient’s specific rehabilitation needs.
Cibolo Creek’s program offers 24-hour nursing coverage, physical/occupational/speech therapies, comprehensive patient education, and wound care.
Additional amenities include in-room telephones and TVs, community dining options, spacious rehab gyms with state-of-the-art equipment, and post-discharge follow-up to prevent rehospitalization.
Summary: The program combines skilled nursing, multiple therapy disciplines, patient education, and supportive amenities for full recovery support.
Transitional care reduces hospital readmissions, accelerates recovery, and enhances patient safety during care transitions.
Evidence shows that well-coordinated handoffs and follow-up care lower complications and improve long-term health outcomes.
Summary: By ensuring smooth transitions and ongoing monitoring, transitional care leads to faster, safer recoveries with fewer setbacks.
Ask your discharge planner for a referral or contact Cibolo Creek directly at (830) 816-5095 to schedule a tour and begin the admission process.
Our team will handle insurance verification, develop your personalized care plan, and coordinate transportation from the hospital to our facility.
Summary: Referrals or self-referrals are welcome. Call us or arrange a tour to initiate your transitional care stay.
We are committed to providing a comfortable, restorative stay after a significant medical experience. Our transitional care goals are to offer exceptional, compassionate, care in a hospitable environment designed to get you home as safely and efficiently as possible. The Cibolo Creek team works closely with you to prevent a relapse and to reduce the chance of rehospitalization. We devise a catered rehabilitation care plan that is designed specifically to get you back to the activities and daily routines you enjoy.