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MVMC Transitional Care



Phone: 406-682-6608 | Fax: 406-682-6618



About MVMC Transitional Care

Madison Valley Medical Center has partnered with Allevant Solutions, a joint venture of Mayo Clinic and Select Medical, to provide the community of Ennis with an enhanced Transitional Care Program.

Our program is designed to make the transition from hospital to home as smooth as possible. We want to make sure that our patients feel comfortable and confident before they leave the hospital–through proper care, education, and assistance. 

Amy Hamilton, RN

Position: Transitional Care Coordinator, RN Case Manager
Contact Amy directly for any admission inquiries

Contact Amy

We provide:

  • Personalized Plan of Care offering pivotal support for a smooth transition back to the home setting
  • Hospital-level nurse staffing with low nurse to patient ratios to keep you safe and help you recover
  • Exceptional physical, occupational and speech therapy services
  • A Home-Like Environment to promote greater success in reaching your rehabilitation goals
  • Personalized Care Team consisting of On-Site Provider, Nursing, Therapist, Pharmacy Team and the Transitional Care Nurse Coordinator
  • Scheduled Care Conferences that engage you, your family, and your care team to help you reach success in your goals
  • Individualized Discharge Planning to coordinate home needs, medications, equipment and any additional resources required to create a successful transition back to your home setting

Patients we care for:

  • After Surgery: Cardiac, neuro, orthopedic, abdominal and more
  • Recovering: From repeated hospitalizations or debilitating illness
  • Wound Care: Special attention for wound healing
  • Intravenous (I.V.) Antibiotics: To treat a variety of infections
  • Requiring Specialized Therapy: Including physical therapy and an array of supportive services
  • Teaching and Training: Education on management of new complex conditions
  • Coordination and Ongoing Assessment of Complex Plans of Care: RN oversight and team collaboration to modify care plans as frequently as patients need

Frequently Asked Questions:

  • What is Transitional Care?
    • Transitional care is for patients who are ready to be discharged from a traditional acute-care hospital but aren't quite ready to go home.  These patients still require additional skilled medical care, nursing care, or rehabilitation services.
  • How long do patients typically stay in Transitional Care?
    • Most stays in Transitional Care are a few days to a few weeks, however, some patients may stay longer if they have daily qualifying skilled care needs. The majority of patients in our program improve their health and rehabilitation status during their stay, and the majority of program patients who lived at home prior to their hospitalization are discharged home after Transitional Care.
  • Is Transitional Care covered by my insurance plan?
    • Transitional Care is predominantly covered by the Medicare "Swing Bed" benefit. Some other insurance providers may cover this care as well. If you are having a planned hospitalization and think you might need care after your stay, we can check if Transitional Care would be covered so you can plan ahead of time to come to our program.
  • Why is the program called "Transitional Care" and is it the same as "Swing Bed"?
    • Our program is called Transitional Care because it is a model focused on helping patients transition from a hospital stay to their highest level of independence at home or in another setting. We use hospital-level resources, team processes, best practices, and extra clinical education to support this "transition". Since most patients receive this care under Medicare, this level of care is sometimes also referred to as "Swing Bed". 
  • How is Transitional Care different from the care received at a Skilled Nursing Facility or nursing home?
    • Because we are a hospital, we can deliver Transitional Care with high levels of safety, quality, and flexibility with hospital-based resources including on-site lab, radiology, and immediate access to physicians and other caregivers. Our hospital-based Transitional Care program provides highly skilled nursing staff with low nurse to patient ratios. We hold Care Conferences with patient, family and care team together on a scheduled basis, so everyone understands your plan of care, identifies things that need to be addressed, and plans for a safe discharge.
  • What should I expect during my Transitional Care stay at MVMC?
    • The goals of your stay are to: 
      • Help you regain your highest level of function facilitating a successful return to a home setting of your choice
      • Remain eligible for the Transitional Care program by creating an individualized Plan of Care to ensure we are meeting recommended guidelines
  • What should I bring with me to MVMC?
    • You will be asked to wear everyday clothes during your stay, some of the most important items to bring from home are:
      • 3-5 pair of pants or shorts. Comfortable, loose fitting pants are best. Jogging suits or Warm Up suits work well.
      • 3-5 shirts or blouses; button or pullover.
      • 3-5 days of underclothing -- Including any incontinence products used at home.
      • 3-5 pairs of socks.
      • Appropriate shoes for walking and wearing during your physical rehabilitation.
      • Warm robe, pajamas or nightgown, and slippers.
      • Any toiletry items.
      • Dentures, eyeglasses, and/or hearing aids, if used at home.
      • Any assistive devices and/or adaptive equipment used at home.