When it is no longer medically necessary for you to remain in the hospital, Gillette Children’s Specialty Healthcare staff is available to assist in finding an appropriate alternative if you are unable to return to your previous living situation and are over the age of 21. 

Skilled Nursing Facility/Transitional Care Unit

You may need to move to a skilled nursing facility/transitional care unit. Transitional care is a bridge between the hospital and home for restorative and rehabilitation care.  Transitional care provides skilled nursing care and is either located in a community nursing home or hospital.  

It is important for you or your family/representative to visit the nursing home/transitional care facility to address your concerns and questions. It is helpful to visit prior to hospitalization if it is a planned hospital stay.  

It is important to consider the following when visiting/selecting a skilled nursing facility/transitional care unit:

  • Location
  • Bed availability
  • Waiting lists
  • Rehabilitation therapy availability and criteria
  • Health insurance contracts/certification  (your health insurance may have contracts with specific facilities)
  • Medicare certification
  • Privacy 
  • Nursing staffing
  • Social services 
  • Length of stay requirements

Admissions vary for skilled nursing/transitional care units so it is important to have second and third choices, if possible.  

Getting There

Hospital staff can assist with arranging special transportation if you use a wheelchair at the time of discharge.

What to Bring

You will be wearing your own clothes at the skilled nursing facility/transitional care unit so it is important that you/your family bring clothes that are washable and easy to get on/off. You may also need personal grooming items. Do not bring valuables, jewelry or personal information.

Legal

If you have a health care directive or legal power of attorney/guardianship documentation, it will be important to bring copies of this documentation.

Payment

There are several ways to pay for a stay in a skilled nursing facility/transitional care unit.

The admissions coordinator at the facility can address which insurances are accepted and if it is Medicare-certified.

Medicare is a national health care program for people 65 or older and for people under 65 who are certified disabled through Social Security. This program will pay for some skilled nursing facility expenses under certain conditions. You must have had a qualified hospital stay (three days or more within 30 days of admission to the skilled facility).

To be covered by Medicare, the skilled nursing facility/transitional care unit must be certified under Medicare. There is limited length of time for payment by Medicare.

Medicare does not cover custodial care, which is care that helps with daily living activities — i.e., walking, eating, and bathing. It must be restorative and meet certain criteria.

Medicaid (Medical Assistance) is a program through the state/county for people with limited assets and income. The facility must be certified as Medicaid-eligible. It is helpful to consult with your county financial worker or case manager/social worker regarding coverage issues related to length of time, services covered and planning for discharge to your previous living situation.

Third-Party Insurance is private health insurance. Coverage varies according to the policy.  

Long-Term Care Insurance is paid for by individual policy holders.  Coverage varies depending on the plan.

Please contact a social worker through Child and Family Services at 651-229-3855 for questions or concerns.

Resources

Disability Linkage Line/Senior Linkage Line  1-866-333-2466/1-800-333-2433

Minnesota statewide information and assistance addressing resource needs and questions about Medicare, health insurance counseling, housing options, and long-term care planning.

Long-Term Care Ombudsman  

Minnesota: 1-800-657-3591
Wisconsin: 1-800-815-0015

Website:  www.medicare.gov  

Resources related to finding a nursing home in your area and comparing nursing homes.

This information is for educational purposes only. It is not intended to replace the advice of your health care providers. If you have any questions, talk with your doctor or others on your health care team.