Frequently Asked Questions

Frequently Asked Questions by Hospitals and Skilled Nursing Facilities

How will the iTransition program benefit the hospital and skilled nursing facility?

Reducing all-cause patient re-hospitalization rate within the first 30 days post discharge.


The goal of the iTransitions program is to provide care coordination prior to and post transition for patients that need placement into senior housing. All of the senior living facilities to which we refer have successfully completed a screening and assessment process and are committed to enhancing transition of care outcomes.

When should the discharge planner refer the patient to the iTransition program?

As soon as it identified that the patient may need senior housing. Ideally, this is during the initial ER visit or hospital admit, but may be any time during the patient’s hospital or skilled nursing facility's stay continuum.


For hospitalized patients with a pending skilled nursing facility transfer for rehab, we encourage the referral to the iTransitions program to be made prior to the skilled nursing facility transfer. This provides the Care Manager with time to complete the Transitional Assessment, discuss patient goals and explore senior housing options with the patient/family.

What if the patient needs housing placement but is resistive to the idea of moving out of his/her own home?

We understand that for some patients moving out of their home is a very daunting task and often times it's a crisis that has forced them to consider a more supportive housing environment. We recommend encouraging the patient to reach out to us, even for informational purposes only. We believe an informed patient is an empowered patient.


Our Social Work Care Managers also work closely with these patients and offer counseling and support, both prior to transition and post transition.

What senior housing options are there for patients needing nursing facility level of care but who do not want to move to a nursing home?

Generally, patients prefer to transition to the least restrictive environment that can meet their care and socialization needs.


If the patient does not need 24 hour skilled nursing care, there are several housing options in the community, other than a skilled nursing facility, which can meet the patient’s high level of care needs. For example, Adult Foster Care homes as well as some assisted living facilities offer 24 hour care and supervision. Some senior housing communities offer a higher level of care than others. Additionally, patients may qualify to receive professional in-home services covered by Medicare, such as: visiting physician, podiatrist, optometrist, dentist and skilled home care services.


The Care Manager will recommend appropriate senior living communities based on the Transitional Assessment, patient preferences and patient’s financial resources. The patient's care needs are matched with the Senior Living Communities' strengths.