Transitional Care

Transitional Care is defined as a broad range of time-limited services designed to ensure health care continuity and promote the safe transfer of patients from one level of care to another, or from one type of setting to another.

Family Resource Home Care provides quality Transitional Care Services by assisting with the medical facility’s discharge plan

When a family member has spent time in a nursing home, rehabilitation center, or hospital, and is preparing to return home, the discharge planning process is critical. Discharge planning takes place when the medical and/or administrative staff of the facility meets with the patient and their family to discuss what needs to happen at home to ensure the best outcome for their soon-to-be ex-patient.

At Family Resource Home Care, we call this service Transitional (or Post-Hospitalization) Care. It can be tailored to any individual who needs temporary assistance, not just seniors.

Find out more about establishing quality Transitional Care services for yourself or your loved one and how Family Resource can ensure that no lapses in quality or services occur during transition.

What is Transitional Care?

Transitional Care is defined as a broad range of time-limited services designed to ensure health care continuity and promote the safe transfer of patients from one level of care to another, or from one type of setting to another.
Research has shown that these transitions represent a particularly vulnerable point for a patient and that well-implemented Transitional Care reduces the likelihood of hospital readmissions. The most recent study, involving Medicare beneficiaries, showed that 19.6% of older adults were readmitted after the first 30 days of hospital discharge, and 34% were rehospitalized after 90 days. Those who were discharged with medical conditions had a 67% readmission rate, and 51.5% discharged following surgical procedures were rehospitalized.
Family Resource Home Care’s Transitional Care Service makes sure that the medical facility discharge instructions are followed explicitly for best outcomes and to reduce the risk of complications or re-hospitalization. To do this we make the facility’s discharge plan part of the home care plan which we develop with you and your loved one. Our services will supplement, not replace, any skilled nursing services covered under Medicare or health insurance.
Transitional Care from Family Resource Home Care covers a range of services reflecting not only the facility discharge plan but other needed services which may include:

  • Transportation from hospital, skilled nursing, or other care facility to home
  • Meal planning and preparation, following dietary instructions or restrictions
  • Medication assistance
  • Assistance with movement, toileting, bathing, and dressing
  • Transportation to follow up appointments
  • Assistance with ongoing therapy (physical, speech, occupational)

The period following a hospitalization is one in which a successful recovery depends on the patient limiting their usual activities and getting the rest they need. One of the most important tasks Family Resource caregivers provide is simply being available for the discharged patient so that the discharge plan can be followed, and the patient will not feel compelled to do more than they should. In addition, not feeling well and/or experiencing discomfort following surgery can create stress. A warm, caring, friendly, and skilled caregiver can do much to alleviate stress as well as provide respite for family caregivers.

Let us help ensure your loved one’s transition to home is seamless

Depending on the situation, you may have weeks or months to plan for the time when you or your loved one is discharged from the hospital, rehabilitation center, or other care facility. Or you may have only a day or two. Whenever it is that you begin to think about what is needed and whether home care is the answer, please contact us. The experts at Family Resource Home Care can assist you with your discharge planning and develop a customized home care plan to support the transition home.

With Family Resource Home Care, you’re never locked into a certain level of service or frequency. Our services are fully customizable, flexible, and are based solely on the needs and wants of the client. Our experienced, highly qualified caregivers can make the transition to home seamless and give you and your loved one peace of mind.

Discharge planning informs Home Care planning

At Family Resource Home Care, we start by listening.

When the time comes, we will review the requirements in the discharge documents, and work with you and your loved one to develop a customized and comprehensive care plan that meets the unique needs of your loved one. This care plan will take into account medical conditions, physical limitations, cognitive issues, medications, instructions from physicians, and the personal preferences of you and your loved one. Some of the tasks in the care plan will come from the discharge instructions, and some will come from the home care assessment we conduct.