A Transitional Care program is a short-term care facility for medically complex patients transitioning from the hospital to home. These patients still need continuous care by medical team and rehabilitation specialists before being cared for at home. The goal of the transitional care hospital is to assist patient recovery by providing the medical and rehabilitative care necessary to help patients regain a certain level of independence. Patient will have a comfortable and relaxing recovery process in a home-like environment in their private rooms with experience medical care team. With the interdisciplinary team approach, we work together to meet our patient’s goal of becoming stronger, more functional and returning home quickly    

Who’s suitable for this care program!!!  

1.Patients aged 15 years old and older, without any restrictions on ethnicity. 

2. Patients eligible for discharge and with a discharge order from the attending physician but are not yet ready to return home, for example, when they are in the process of home environment adjustments or seeking a home caregiver. 

3. Patients with stable conditions who are deemed fit to return home with clear instructions from the attending physician. However, the patient and family are in the process of preparing for home care and still require nursing assistance, such as tube feeding, suctioning.   

4. Cases of bedridden, in stable condition, and do not have active physical or mental problems requiring medical supervision, and do not have wounds resulting from pressure sores or IAD requiring treatment from a doctor. However, they still require nursing care to assist with daily activities, such as administering tube feeding, repositioning the body, or suctioning mucus. 

5. Patients in the rehabilitation phase or those who require continuous rehabilitation services, whether they are patients from the Department of Internal Medicine or Surgery   6. Patients who can assist themselves to some extent (Partially dependent), perform activities of daily living, with a Barthel ADL Index equal to or greater than 40, and have stable vital signs. Their cognitive abilities are within normal limits. 

 7. The patient and family have a plan to stay at the Transitional Care Ward for a period not exceeding 3-6 month