If you are a physician or discharge planner whose patient requires short-term skilled nursing and rehabilitation care before transitioning from the hospital to home, Emerson Hospital’s Transitional Care Unit is here to help.
Like you, we aim to avoid hospital readmissions by providing attentive, appropriate care to help patients regain their strength and function.
Here is an overview of how to refer a patient to our Transitional Care Unit:
Who is appropriate for transitional care
The Emerson Hospital Transitional Care Unit accepts patients with these conditions:
- Orthopedic: Total joint replacements (including bilateral knee replacements), fractures, spinal surgery, falls, trauma
- Post-surgical: Cardiac, vascular, complex GI (drains), plastic/reconstructive
- Neurological: CVA, Parkinson’s, multiple sclerosis
- Cardiopulmonary: Heart failure, COPD, interstitial lung disease
- Complex medical: Pneumonia, IV antibiotic therapy, PICC lines, established tracheostomies
- Complex wound care: Including wound-VAC (vacuum-assisted closure) therapy
- Central parenteral nutrition to support medical/surgical recovery
- Chronic kidney disease: Outpatient chronic dialysis for patients with acute conditions
- Oncology: Patients undergoing radiation and/or chemotherapy who need to regain strength
- Hospice: When rehab goals change, the plan of care can be adjusted to include end-of-life care
Health insurance coverage
We accept most insurance plans, including traditional Medicare and Managed Medicare for recipients who qualify for direct admission to the Transitional Care Unit from an emergency department, their physician’s office or home through the ACO three-day waiver. Emerson is a preferred provider for the Partners HealthCare and Atrius Health ACOs.
To make a referral
Simply call our nurse liaison at 978-287-3620