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Transitional Care Network

Your bridge from hospital to home

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The Transitional Care Network (TCN) provides on-site primary care to patients while they transition from the hospital to home or an alternative-care setting.

The TCN is a network of transitional care units located within long term care centers. This network was created to give patients the ability to have a Fairview doctor and nurse practitioner provide their primary care on-site after being hospitalized at Fairview Ridges Hospital, Fairview Southdale Hospital or the University of Minnesota Medical Center, Fairview.

Visit our  commonly asked questions or contact us directly to learn more.

Why Use Fairview TCN?

The 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 participating network location 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.

Our doctors and nurse practitioners work with you, your family and the rehabilitation staff to develop an individualized care plan. You will receive all of your primary health care services from this team.

When you get to the transitional-care unit, your doctor and nurse practitioner will work with you to agree on goals you need to meet. How long you stay depends on how long it takes you to meet these goals.

Once you are ready to leave transitional care, the doctor and nurse practitioner will communicate with your primary doctor 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, the transitional-care unit social worker will arrange for them.

With our program, you can rest assured you are receiving the best care possible as you move from the hospital to one of our transitional-care units and then home or to an alternative-care setting.

Commonly Asked Questions

What do I need to bring with me?

• Comfortable, loose fitting clothing suitable for exercising
• Underwear, socks, pajamas, bathrobe and toiletries
• Walking shoes and non-skid slippers
• Medicare, Medicaid or other insurance cards and social security card
• A copy of your Health Care Directive/Living Will

Where will I eat my meals?

It is strongly encouraged that you eat in the dining room, as it is part of your therapy.

How do I get my medications?

The facility receives orders for your medications from the doctor. The nurses will give them to you. The medication is provided as part of your stay so you do not need to bring any medicine from home.

Can my family visit?

Yes, family members are very welcome. Visits need to be scheduled around your rehabilitation schedule.

How do I get to medical appointments from the facility?

You can either be driven by a family member or friend or use a medical transportation company. If you use a medical transportation company you may have to pay for it yourself because medical insurance does not always cover the cost.

How long will my insurance cover my stay at the facility?

The hospital social worker or someone at the facility where you are going will contact your health care insurance company. How much is covered depends on the benefits of your health insurance policy, your medical needs and the progress you make at the facility.


Contact Us

The TCN is a participating provider for most local health plans and major insurance plans, as well as Medicare and Medicaid.

If you have questions and would like more information: Talk to your hospital licensed social worker or contact the TCN directly.

Fairview Transitional Care Network
3400 West 66th St., Suite 290
Edina, MN 55435

612-672-7272

fvpartners@fairview.org

 
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