Sub-Acute Rehabilitation

Transitional Care Medicine refers to the coordination and continuity of care during movement from one healthcare setting to another.  We recognize many patients with complex needs are at risk for readmission to the hospital due to lack of proper follow up care post-discharge, including following up with medications, and also failure to communicate with patients’ families or caregivers.  Under the direction of Dr. Jason Shatkin, our stellar transitional care team is led by Stephanie M. Salimbene, MSN, APN, FNP-BC,  Monica Fernicola, RN, MSN, APN-BC and Danjela Ago, MSN, APN, FNP-BC, who work closely with patients, referring providers and case workers to ensure a smooth transition from the subacute rehabilitation setting to home.

PSONJ’s Sub-Acute Team currently has privileges seeing patients at CareOne at Ridgewood Avenue (Skilled Nursing) and CareOne at the Cupola (Assisted Living), some of the highest rated facilities in Bergen County.  Whether a patient is transitioning to the sub-acute setting from an in-patient hospital stay, or they require rehabilitation post-surgery, injury, fall or etc., our expert team provides excellent care with the goal of helping patients fully recover and regain functional abilities so they can return home rather than declining and being re-hospitalized.  Our Practitioners provide a comprehensive care plan discussing patients’ treatment goals and preferences, as well as tracking health/clinical status changes.  This care plan also includes logistical arrangements, full advocacy and communication with family members, as well as coordination of care between primary care physicians and all healthcare professionals involved in the patient’s rehabilitation.