Skilled Nursing Care - Come Back Home

Ottawa County Health Center (OCHC) would like to welcome you to Come Back Home to your hometown hospital for additional care or rehabilitation following illness or surgery at another facility. The Come Back Home Swing Bed program allows you to return to OCHC for skilled nursing care and rehabilitation to assist in your recovery. Together we will work with you, your family or caregiver, and your local provider to make the necessary arrangements to allow you to safely return home once you are ready to leave OCHC.

The following information provides a more in-depth overview of the Come Back Home Swing Bed Program at OCHC. 

The Swing Bed program allows a physician to transition (or “swing”) a patient’s care from acute medical need to skilled nursing or rehabilitation. A patient being treated for an acute condition can remain in the hospital for follow-up care rather than be discharged home when they are not quite ready. The patient stays in the same bed, receives the same care, but the services are billed differently. Qualifying for the swing bed program assumes that the patient has the ability to improve and achieve higher levels of functioning. The goal is an individualized plan of care directed towards meeting the patient’s needs. The decision to transition to a swing bed is made through a consulting process between the patient, his or her family, the physician, the nurses, and the discharge planners/social services.

The Swing Bed program provides a viable option for patients in need of skilled services in the local community, keeping them close to home and family. The Swing Bed program can help patients prepare for a safe and sustainable return home. It can also reduce re-admissions and provide great nurse/rehabilitation ratios. The goal is to help the patient return to his or her home independently or with the help of other community resources.

Skilled care is rehabilitation and skilled nursing that allows patients additional nursing care, rehabilitation, and other professional services following surgery or illness. It is important to understand that skilled care implies the need for professional care and monitoring, whereas “nursing home care” can be skilled or custodial care. 

Nursing Services will develop an Individualized Care Plan with the goal of allowing the patient to return to the highest level of functioning possible. Some skilled services include:

• Nursing Care
• Intravenous (IV) or intramuscular (IM) injections
• Nasal-gastric/gastro/jejunostomy feedings
• Treatment of decubitus ulcers (stage 3 or worse) and or other types of wounds
• Application of dressings with prescription medications and aseptic technique
• Professional Observation
• Medical conditions (such as uncontrolled diabetes or acute CHF)
• Vital signs for special purposes (such as specific medications)
• Psychiatric conditions (such as depression, anxiety, or suicidal behavior)
• Teaching or Training
• Newly-diagnosed diabetic education
• Care of Hickman catheter or central lines
• Specialized dressings and skin care
• Medication management of newly prescribed medications

Rehabilitation Services will do an initial assessment of the patient’s condition, needs, and potential, and then ongoing assessments of his or her progress. Depending on the patient’s needs, rehabilitation services may include:

• Physical Therapy - The Physical Therapy team works to improve the patient’s endurance and help to resume his or her life activities (such as walking, exercising, improving balance, strength, and flexibility). Therapists also educate the patient and family on safety and mobility.
• Occupational Therapy - Occupational Therapists work to restore independence in daily living after an illness, injury, or surgery. They provide education and training to accomplish tasks to avoid pain and fatigue. Therapists will assess the need for assistive devices and provide any necessary training.
• Speech Therapy - Speech Therapists assist patients with dysphagia (difficulty in swallowing), interpreting and remembering written and spoken statements, and expressing thoughts through speaking, writing, and facial expressions.
• Pharmacy Consultation - The Pharmacist with meet with the patient and family members to assist with chronic medication management and/or new medication education and management.
• Case Management - The Case Manager will assist the patient and/or family members with goals including discharge planning, personal resources/financial needs, and family communication.
• Nutritional Therapy - Nutritionists and Dieticians support and education to the patient and their family to promote the optimal nutritional health.

• Prior to swing bed status, Medicare patients must have a 3-day Inpatient qualified stay and require skilled nursing or rehabilitation as defined above.
• A physician must determine that the patient needs daily skilled care. Care must be given by, or under the direct supervision of, skilled nursing or rehabilitation.
• A patient can be in swing bed status while awaiting a bed at another facility.
• A patient can stay in swing bed status as long as he or she is working toward the identified goal for rehabilitation or still has a skilled nursing need.
• As part of treatment, the patient must cooperate in the plan of care, which will be explained to the patient and his or her family by the OCHC Case Manager.

• The Swing Bed program is available to all types of insurance. Benefits will vary based on the patient’s specific coverage. Patients can contact their insurance provider or the OCHC Case Manager for assistance.
• Medicare will cover a skilled bed if the patient has Medicare Part A with days left in his or her benefit period available to use.
• Medicare coverage is limited to 100 days of skilled swing bed care per benefit period. If the patient meets skilled criteria, Medicare will cover 100% of the first 20 days. The patient may be discharged before 20 days if skilled criteria ends. After 20 days, Medicare Part A covers up to an additional 80 days with the patient paying coinsurance each day.
• Depending on the length of stay in the swing bed program, there may be coinsurance that the patient will be responsible for.
• No Medicare benefits are available after 100 days in a skilled program (Swing bed) during a benefit period. Please refer to the Medicare handbook or speak to the OCHC Case Manager about these matters.

You and your family are encouraged to participate in planning your health care program. We encourage you to speak with the OCHC Case Manager regarding your wishes about your care, comfort, rehabilitation and medications.

For more information about the OCHC Come Back Home Swing Bed program, please contact the OCHC Case Manager at (785) 392-2122.

For information on the OCHC Swing Bed Program, contact the OCHC Case Manager at (785) 392-2122. 

For information about Medicare or to get answers to questions regarding the Medicare program, call toll free 1-800-772-1213.

For information about Medicaid, call toll free: 1-800-792-4884.