Coordinated Care After Hospital Discharge

Whether a hospital stay for surgery, illness or injury was planned or not, it can be a stressful time for the patient as well as family members. The SpiriTransition program can help you navigate the system and make a smooth transition out of the hospital to return home safely, confidently and independently, and back to everyday activities.

Speed Your Recovery with
Care Focused on You

Through the SpiriTransition program, team members from SpiriTrust Lutheran® work together to improve care coordination for all the services you need to return home for a successful recovery – from the notice of hospital discharge to the SpiriTrust Lutheran Skilled Care Center of your choice to Home Health Care. This program has helped SpiriTrust Lutheran rank among the highest-rated skilled care centers for maintaining low re-admission rates.

Choose a SpiriTrust Lutheran Skilled Care and Rehabilitation Center at one of these communities:

Single-Point Coordination Driving an Experienced Team of Professionals

The experienced team members of this program include social workers and registered nurse liaisons, who coordinate and provide oversight of all Home Health services. This single-point coordination helps to eliminate gaps in needed care and services, reducing frustration and confusion for you and your family members.

Trying to coordinate care for yourself or a loved one who is hospitalized or planning for a surgery?

 Let the SpiriTrust Lutheran Skilled Care and Rehabilitation Center of your choice or your hospital discharge planner know your desire to utilize the SpiriTransition program, and we’ll take care of the rest. Contact us at one of our communities below: