Transitional Care

Transitional care is a coordinated set of actions that bridge a patient’s move from hospital to post-acute or home settings. It ensures continuity of medical oversight and therapy to prevent complications and reduce readmissions.

Summary: Transitional care maintains clinical momentum after discharge, leading to safer, faster recoveries.

A team of physicians, nurses, social workers, therapists, and pharmacists collaborates on each patient’s care plan. They use evidence-based practices to tailor treatments and prevent rehospitalization.

Summary: Physicians, nursing staff, therapists, social workers, and pharmacists work together to optimize outcomes.

Transitional care may be an option if you suffer from pain, stress or other side effects due to an illness or disability. Illnesses or disabilities may include but are not limited to: Cancer, congestive heart failure, respiratory diseases, multiple sclerosis or recovering from a fall or procedure.

Transitional care focuses on seamless handoffs and comprehensive care coordination, whereas inpatient rehabilitation emphasizes intensive therapy to restore function. Transitional care teams manage discharge planning, follow-up, and multi-disciplinary oversight, while rehab care provides daily physical, occupational, or speech therapy.

Summary: Transitional care ensures continuity and oversight; rehabilitation care delivers targeted functional therapies.

Patients leaving the hospital after surgery, serious illness, or acute events who still require skilled nursing and therapy qualify for transitional care. Eligibility typically includes those recovering from joint replacement, heart disease, stroke, pulmonary illnesses, wound care, or IV therapies.

Summary: Any discharged patient needing ongoing clinical support and therapies before returning home is eligible.

Cascade offers 24-hour nursing, physical/occupational/speech therapies six days a week, patient education, and post-discharge follow-up. Amenities include in-room or community dining, cable TV, family lounges, and state-of-the-art rehab gyms.

Summary: The program combines round-the-clock clinical care, multi-therapy services, and comfort-focused amenities.

Cascade’s discharge planners arrange follow-up care and monitor patients after they leave the facility. Regular communication with primary providers and targeted education on warning signs further reduce relapse risks.

Summary: Coordinated follow-up, provider communication, and patient education minimize readmission rates.

Private and semi-private rooms, family areas, and hospitable dining spaces create a home-like atmosphere. Spacious rehab gyms equipped with advanced therapy tools support efficient recovery.

Summary: Comfortable accommodations plus modern gym facilities encourage rest and therapeutic progress.

Referrals are arranged by hospital discharge planners or by directly contacting Cascade’s admissions team at the facility. Our staff handles insurance verification, care planning, and transportation coordination.

Summary: Arrange care through your discharge planner or by calling Cascade’s admissions office.