Your Plan of Care

Your physician and a dedicated team of professionals will be working closely with you to implement a plan of care that will help you reach the health goals established by you and the team. We are committed to making your stay here as comfortable as possible and to help you obtain your optimal level of physical, emotional, and spiritual health. Members of our interdisciplinary team include:


A Clinical Director and Nurse Manager coordinate the operation of the Transitional Care Unit and assure that safe and effective care is provided to each patient.


Our skilled hospitalists will be responsible for your total care while you are a resident of the Transitional Care Unit. The hospitalist may order consultation services from a variety of specialists, including dentists and ophthalmologists. A listing of these services is available upon request. Your physician is only required to visit weekly in TCU, but will be notified of any problems that occur.


The nursing staff of the Transitional Care Unit gives individualized, consistent resident care 24 hours a day, seven days a week.

Some of the issues that are addressed include bowel and bladder control, keeping your skin healthy, wound care, self-medication, intravenous therapy, and others.

You may request private duty staff at your expense. Our staff is available to help make arrangements for these services if desired.


The dietitian will discuss with you what foods you prefer and what foods are needed for your therapeutic diet plan.

The dietitian will also teach you about any changes you may need to make in your diet at home.

Physical Therapy

Physical therapists are available to work with you to overcome the weakness, immobility, and/or other physical impairments that are sometimes caused by illness, disability, or injury.

The primary focus of physical therapy is to assist you to regain your former level of functioning through exercise, bed and wheelchair mobility, transfer training, and walking skills.

Occupational Therapy

Occupational therapists are available to assist you in attaining independence in activities of daily living which include feeding, bathing, dressing, hygiene, and homemaking.

To help you achieve independence, adaptive equipment such as a wheelchair, shower chair, special feeding tools or utensils and splints may be recommended.

Speech Pathology

The speech/language pathologist works with the staff and your family to develop strategies that will increase your ability to communicate and/or swallow.

Speech pathologists also provide treatment for communication disorders and problems with reading, writing, attention, memory, and reasoning.


Activities are an integral part of your care to help you improve functional abilities and maintain leisure activities to enhance your health and well being when you go home.

An activity calendar will be posted in your room and in the Dining/Activity Room. You will be encouraged to participate in social and recreational events.

Discharge Planning

The Continuity Care Planners provide support to you and your family in the areas of lifestyle transition, planning for future therapy, and for care after your stay in the Transitional Care Unit.

Continuity Care Planners will help you to develop a comprehensive discharge plan and locate appropriate community resources to assist you with your return to the community.

Transitional Care Unit beds will not be held if the resident is readmitted to the hospital or other therapeutic facility. The bed will be retained if the resident is out for observation, admission, ambulatory surgery, or a special exam/treatment.


Serious or chronic illness often brings emotional and/or financial stress to you and your family, affecting your ability to function and recover and your family’s ability to cope.

The social worker can provide supportive counseling to you and your family or arrange for psychological services to help improve your psychological and social well being.

Pastoral Care

Pastoral counselors are available on the Transitional Care Unit for your spiritual welfare and comfort and can visit you.

If you prefer, we will be happy to contact your rabbi, priest, or pastor.

Clergy may visit at any time, day or night. Arrangements for a private visit can be coordinated with our staff.

Hospital Services

All services available to patients at Passavant Area Hospital are available to residents in the Transitional Care Unit.

Special diagnostic procedures and studies are to be ordered by your physician.

Emergency services, including the administration of life support, can be initiated at Passavant.