Steps to Home program at St. Luke’s

Published 8:49 am Monday, November 27, 2023

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Have you noticed how quickly patients are discharged from hospitals these days? In many cases, what was once an inpatient procedure has become outpatient. The reduction of hospital stays is not unique to St. Luke’s. Healthcare payers began evolving the length of stay model a couple of decades ago as outpatient outcomes dramatically improved nationally. Even some neurosurgeries are on a 23-hour observation protocol, which is amazing!

The models work as intended for most of the population. Still, older adults needing a hospital stay sometimes bounce back slower than once, necessitating further conversations with payors about approval for an extended stay. Many of these patients are too well for an acute care hospital bed per medical necessity guidelines but still require skilled nursing care to regain the strength and skills needed to return home successfully. In our region, 49% of the population is over 55. And statistically, older populations have a much greater need for hospitalizations. 


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The Social Security Act has allowed some rural hospitals to use their beds for acute care and nursing care (swing bed). A swing bed hospital is a critical access hospital approved for post-hospital skilled care. St. Luke’s, one of these hospitals, has provided extended post-hospital care for about two decades. We call our program “Steps to Home,” which treats rehabilitation-oriented medical conditions instead of chronic ones.


Steps to Home (skilled care) at St. Luke’s ensures our patients receive one-on-one rehabilitation, helping them achieve the highest level of independence. Moreover, our average six-to-one patient-to-nurse ratio or better is unparalleled among local swing bed programs.


Steps to Home is for Medicare Part A patients who’ve experienced a severe illness or surgery. Acceptance into the program begins with an application process that the hospital’s case manager handles. If admitted to St Luke’s, you’ll receive an evaluation to identify critical physical needs, followed by an individualized rehabilitation curriculum. If you are an inpatient at St Luke’s, our case management department will evaluate your potential need for swing bed-level care throughout your admission. Should your care begin at another hospital, please always request to be transferred to St Luke’s for your post-acute care to ensure the hospital case management team is evaluating during your stay.

Who benefits from our program?

  • Patients who need rehabilitation after orthopedic surgery
  • Patients recovering from a stroke or a cardiac surgery
  • Patients who need long-term IV therapy
  • Patients requiring wound or burn care
  • Patients who need strength rehabilitation after an illness or injury 


The onsite St. Luke’s interdisciplinary team includes 24/7 physicians & advanced practice providers, skilled registered nurses, respiratory therapists, physical therapists, occupational therapists, speech therapists, pharmacists, dietitians, and case management. During your stay, you’ll have consult access to specialists as needed. 

We’ve found the support of family and friends is extremely important to patient recovery. Patient care conferences are also essential to recovery; we invite family members to attend.

Upon discharge, and to promote home safety, we may refer our patients to home health or outpatient services for additional treatment if needed.


  • Hospital care model
  • 24/7 onsite physicians
  • 24/7 emergency department
  • Onsite pharmacy
  • 8,000 sq. ft. rehab center
  • An average 6-to-1 patient-to-nurse ratio or better
  • World-class imaging

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