The transitional care network (TCN) offers a supportive environment for people who no longer require all the resources of a hospital, but who are still unable to return home. Most people come to a TCN facility from an acute care unit of a hospital or for continued, less intensive care after surgery. This healing environment helps ease the transition back to home or to an alternative care setting, while encouraging each person to be as active and independent as possible in his or her own care.

Our primary health care teams, comprised of a Fairview affiliated physician and geriatric nurse practitioner, work with you, your family and the rehabilitation facility staff to develop an individualized care plan. You will receive all of your primary health care services from one medical team that knows you, your medical history and health concerns.

When you get to the rehabilitation facility, you and your care team will agree on goals you need to meet. How long you stay depends on how long it takes to meet these goals.

Once you are ready to leave transitional care, the care team will communicate with your primary care physician so that he or she is aware of what went on during your stay including an update on any medication changes. If any additional services are needed, your facility social worker will arrange for them.

Coordination of care is extremely important for each person. With the TCN, you will receive the best care possible as you move through the hospital to one of our transitional care facilities and then home or to an alternative care setting.

If you have questions about the TCN, please review our commonly asked questions or contact the TCN directly.