Transitional care services enhanced
St. Mary’s and Clearwater Valley Hospitals are enhancing their transitional care services for patients who need additional rehabilitation and skilled nursing care prior to returning home.  Kathy Seubert, RN, SMH Director of Nursing Services and Discharge Coordinator, works with patients who would like to return to St Mary’s Hospital for recuperation and rehabilitation after having specialized procedures done elsewhere.
“Many people need surgery with specialists who are not available locally and some patients are transferred elsewhere when they’ve had a stroke or injury.  Sometimes patients don’t realize they can come back to Clearwater Valley or St. Mary’s Hospital for follow up hospitalization to help them transition back to their homes,” said Sharon Moriarty, DNS, Clearwater Valley Hospital.  “We’ve had a number of people tell us they’d prefer to be back in their home communities to fully recuperate, but didn’t know they could transfer from a distant hospital back here.  We provide rehabilitative services such as hospital based physical therapy, speech and respiratory therapy in addition to IV therapy and wound care.  We’re letting people know they have this option.”
The hospitals also provide a Visiting Nurse Service program that provides in-home nursing care, when necessary, once the patient leaves the hospital.
We have discharge planners at both facilities that can help with the transfer of a patient from a distant hospital to ours.  They also work with families and patients to ensure a smooth transition when the patient returns home or to a long term facility, said Moriarty.
The Center for Medicare and Medicaid Services has different definitions and reimbursement rates for levels of service.  Acute care service involves the provision of nursing services 24/7 and skilled nursing, swing bed or transitional care services also require various therapeutic services and recreational planning.  “The regulations are complicated and in the best interest of the patient,” said Kathy Seubert, DNS, St. Mary’s Hospital. “Our discharge planners and utilization review coordinators are well versed in those regulations. We want patients to know they have a say in where they receive those services.  Patients who must go elsewhere for their surgery or other services can transfer back to their community hospital for continued care prior to returning home.  Returning to our hospitals means patients can be close to their family, friends and family doctor while they recuperate.”
CVH and SMH serve residents of Clearwater, Idaho and Lewis counties. For more information about local transitional care services call St. Mary’s Hospital, 962-3251 or Clearwater Valley Hospital, 476-4555 and ask for the Director of Nursing Service or Discharge Planner.  The toll free number for the SMH/CVH Visiting Nurse Service program is 1-800-497-7412.

Cottonwood, Idaho 83522


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503 King St.
P.O. Box 157
Cottonwood, ID 83522-0157
Fax 208-962-7131
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