Post-Acute Care & Transitions (PACT) Team

From the moment of discharge, we make every minute matter.

Each post-acute care patient has a story, and put simply, listening well is how we build individualized patient plans for the next steps in a patient’s journey. The Marion Health post-acute care team provides a continuum of care that bridges the gap from hospital to home.

How Does the Program Work?

The Post-Acute Care Program is built around a team that coordinates treatments across skilled nursing, long-term care, nursing homes, assisted living facilities and rehabilitation facilities. Our post-acute care clinicians help prevent avoidable readmissions, improve alignment between post-acute/acute facilities and promote successful care transitions while striving to provide a higher standard of patient care. We assist in coordinating patients’ access to diagnostic testing, lab services, and treatments required outside the hospital.

Post-acute care is provided to those who are recovering from acute illness or suffering from a chronic illness. These residents most often come to us from a hospital and we work with a range of medical care services to continue their recovery. This recovery process often involves physical, occupational and speech therapies.

The post-acute care team works closely with the patient’s primary care provider (PCP) and the hospitalists to manage complex medical and social needs of our patients. The team continues counseling patients, even as they return home; overseeing the ordering of essential medical equipment, as well as providing their primary care provider with medication changes and a progress summary of the patient’s condition.

What are the benefits of Post-Acute Care?

Quality care begins with understanding each patient’s unique needs. We’re empathetic, attentive and engaged in each patient’s experience and the individual challenges faced at every stage of transitional care.

Searching for quality nursing care can sometimes be confusing and overwhelming. We are here to assist you in making the most informed and appropriate decisions to meet your healthcare needs