Transitional care provides invaluable help for individuals and families who require additional support following hospitalization or after a stay in a skilled care facility. Transitional care professionals assist with key services like medication management, follow-up care, and much more. Whether recovering from a surgery or long-term illness, or if your loved one needs extra support due to age-related conditions, transitional care helps establish goals and create action plans to help them adapt and thrive.
Learn more about transitional care(Opens in a new window) and how it can help support greater independence between different stages of health and recovery.
What Is Transitional Care?
Transitional care is an umbrella term that encompasses a range of services designed to help individuals and families make successful transitions from one stage of health care to another. The goal of transitional care is to help individuals manage their health and maintain their independence by providing them with the resources they need as they move through different stages of treatment.
Transitional care can be tailored to fit individual needs and includes services such as physical therapy, occupational therapy, social work, nutrition counseling, medication management, and more. Transitional care also includes follow-up visits with primary healthcare providers and specialists.
Types of Transitional Care Services
There are three types of transitional care services. Each benefits specific aspects of a person’s health and/or recovery journey – and in many cases, there is an overlapping need for more than one of these services.
- Medical Support: Skilled nursing care including wound care, medication administration, monitoring and recording vital signs. Skilled medical support can also document a client’s recovery progress and work to adjust a care plan as their recovery progresses.
- Non-Medical Support: Professional in-home caregivers can assist with meal planning and preparation, mobility assistance and transportation to appointments. They can also provide support with activities of daily living (ADLs) like bathing, grooming, toileting and dressing.
- Emotional Support: In many situations, emotional support can help boost a person’s outlook and attitude, playing a key role in their recovery. Companionship, conversation and social activities to ease the emotional frustration that often accompanies healthcare transitions.
Who Is Transitional Care For?
Moving on from one health care setting to another can be a tricky situation for anyone, and that's where transitional care comes into play. This type of care provides essential support for people as they navigate their way from a hospital or nursing home back to their home, or even as they move into an assisted living facility. It can be a true lifeline, helping to ease the transition and ensuring that individuals have the proper resources and guidance they need to move forward with confidence in their health and wellness.
Who Benefits from Transitional Care?
People who are recovering from or adapting to a variety of health scenarios can benefit from transitional care. Individuals with chronic illnesses, those recovering from a major medical event such as a stroke or heart attack, or people who have recently been released from the hospital following surgery can all benefit from transitional care. Let’s explore some of the various scenarios where transitional care can help pave a smoother path to recovery.
Post-hospitalization recovery: Clients dealing with major medical events such as strokes, heart attacks or recovering from surgery benefit from continuity of care and ongoing professional medical support while they recuperate at home.
Hospital to ongoing home care: When your loved one no longer needs hospitalization but requires continual support for new or changing health conditions, transitional care can help them mentally and emotionally prepare them for the next stage of recovery.
Chronic illness management: Transitional care can be especially helpful for those dealing with a new or evolving diagnosis. Transitional care can help people with a chronic illness navigate valuable resources and receive support with managing symptoms and potential lifestyle adjustments.
Caregiver support: Family caregivers often need assistance in understanding how best to manage their loved one’s condition at home after they’ve been discharged from a hospital or rehabilitation center.
BrightStar Care's Role in Transitional Care
At BrightStar Care our team works closely with your medical providers throughout your transition process so that you get the personalized attention you need during this critical time. Our team will coordinate follow-up appointments with all involved parties so that there is continuity between each step in the process, allowing you or your loved one's recovery journey to go as smoothly as possible while providing peace of mind for everyone involved.
How Does Transitional Care Work?
Once you are notified of your loved one’s hospital discharge date or otherwise become aware of a healthcare change, we can begin the process of putting transitional care in place. Our care team is committed to working closely with your family members and existing medical team to create the best plan possible for your loved one’s next stage of care.
Your personalized care plan can include assistance with hospital discharge and transfer to home, coordinating follow-up appointments, managing medication and support with physical or occupational therapy. Whether your loved one needs medical, non-medical, or companionship support, our team of professional caregivers put communication at the heart of our approach to care. We’ll work hand-in-hand with your family, caregivers and your loved one’s physicians to provide open channels of communication throughout their recovery process.
Benefits of Transitional Care for Patients and Families
When it comes to transitional care services, there are many benefits to receiving in-home care. One major benefit is that your loved one can recover in the convenience and comfort of their own home. Transitional home care alleviates the complication of transportation to and from the hospital or rehab center, as they can receive care right where they live. This can be especially important for individuals who have limited mobility or who have difficulty getting around.
Transitional care provides a safer alternative to hospitalization or extended stay in a care facility. Working with a small, expertly-matched team of in-home caregivers helps ensure coordination of care and that your loved one can recover in familiar surroundings. Transitional caregivers can assess the home for any potential hazards that could lead to trips and falls, educate a client and their family about their condition, and consistently monitor an individual’s progress. In-home transitional care also helps avoid issues such as medication errors, missed follow-up appointments or relapses.
Personalization
Another benefit of in-home transitional care services is the level of personalization that can be provided. At BrightStar Care, we understand that no two individuals are the same, and their care needs vary. Through our transitional care services, individuals receive personalized care that addresses their specific needs, including personal services such as light housekeeping, meal prep, and medication management. This level of customization allows individuals to receive the care they truly need, promoting a faster and more comfortable transition back to home and routine.
In addition, receiving care in the home can be less stressful for both the individual and their loved ones. Receiving care in the home allows the individual to have greater control over their surroundings, which can be especially important for those who may have anxiety or other conditions that can be exacerbated by an unfamiliar environment. Similarly, this can provide much-needed peace of mind for family members, who can rest assured that their loved one is in a familiar, comfortable environment that promotes healing.
Cost Savings
The financial cost of hospitalization, residential facilities or frequent travel for care can be significant. In-home transitional care offers a solution that eases that financial burden. Each situation is unique and costs will depend on the level of care required, frequency of visits and geographical location. However, in-home transitional care is almost always much more affordable than the alternative solutions, such as a care facility or hospital.
Improved Convenience and Accessibility
In-home transitional care supports clients recovering from surgery or managing chronic conditions with a focus on convenience and accessibility. Clients who cannot drive or have mobility concerns can still receive top-notch care in the comfort of their home.
Positive Outcomes
In-home transitional care can help create more positive outcomes(Opens in a new window) and measurable benefits. Medically, most clients and medical professionals report faster recovery times, fewer complications, and reduced hospital readmissions. Additionally, clients often have more positive recovery experiences overall, less stress and anxiety, and higher levels of comfort and ease while receiving in-home care.
How to Prepare for Transitional Care Services
Moving back home from a hospital or nursing facility following surgery or another major medical event can be overwhelming, but BrightStar Care is here to help ease that strain. To better prepare for the transition to in-home care, start by familiarizing yourself with the discharge process. Ensure you have the necessary medications and recovery supplies such as bandages or walking aids. You’ll also want to proactively arrange follow-up visits and appointments. Remember that your loved one’s current medical team can answer your questions and that we are here to provide support to you every step of the way.
Short-Term Transitional Home Care Services Offered by BrightStar Care
Our BrightStar Home Care(Opens in a new window) team of registered nurses are dedicated to helping you transition safely back home. With a wide range of in-home services(Opens in a new window), we provide personalized plans that ensure your health needs are met with the utmost care and accuracy.
Conditions We Support
We provide specialized care for individuals recovering from or managing:
- Chronic Obstructive Pulmonary Disease (COPD)
- Diabetes
- Heart Attack/AMI (Acute Myocardial Infarction)
- Heart Failure
- Pneumonia
- Post-Operative
- Stroke
- Therapy for Post-Op or Stroke
Transitional care management includes multiple services to ensure proper healthcare delivery for patients. It involves obtaining and reviewing patient discharge information, assessing the need for further diagnostic tests and treatments, providing education to the patients and caregivers, establishing referrals to and arranging for community resources, scheduling follow-up visits with various services, and coordinating care with home and community-based clinical service providers.
A critical aspect of transitional care is the reduction of unnecessary hospital readmissions and medication management. BrightStar Care seeks to make the transfer from hospital to home as seamless and efficient as possible, ensuring patients are comfortable and well taken care of throughout the process.
Local Care, Nationwide Reach
BrightStar Care transitional care services are conveniently located around the country(Opens in a new window), allowing you access to the help you or a loved one need when you need it most.
The Role of Caregivers in Transitional Care
The stress of experiencing a major medical issue is difficult on the body and mind of your loved one, as well as the rest of your family. Family caregivers play a key role in supporting transitional care, having walked the path with them from diagnosis to treatment to recovery. While family caregivers are an essential component of your loved one’s care, our professional care staff can assist in managing those responsibilities, giving you a break from hands-on caregiving and giving you peace of mind that your loved one receives quality, compassionate care.
Choose BrightStar Care Today for Your Transitional Care Services!
Transitioning between different stages of health-related situations can be overwhelming without proper guidance and support; this is where transitional services come into play! At BrightStar Care(Opens in a new window), our team works closely with you or your loved one during this critical time, ensuring a seamless transition process with personalized care plans tailored to your needs. We are committed to continuous support, coordinating with healthcare providers to guarantee a smooth recovery at home. With our help, you can ensure that your recovery goes as smoothly as possible while providing peace of mind for everyone involved! Contact us today(Opens in a new window) if you have any questions about our transitional services! We look forward to hearing from you soon!
Frequently Asked Questions
Transitional care is an increasingly popular option for clients who are moving from one stage of healthcare to another. While family caregivers are a key pillar of their loved one’s support system, professional in-home transitional care can make a difference in recovery time for your loved one and provide you with much needed support.
What is an example of transition of care?
Transition of care refers to any situation in which the client is moving from one stage of health care to another. Most of our transitional care clients move from needing a high level of medical care to a lower level of medical or personal support.
- Some examples of transition of care are:
- Post-operation or surgery recovery
- Recovery from a heart attack or stroke
- In-home support after a rehabilitation center stay
What is the transitional care period?
How long someone will need transitional care depends upon a variety of factors, including the severity of the medical issue at hand, treatment plan and estimated recovery time. Some clients may need transitional services for only a couple of weeks while others may need ongoing care for months or years.
What is the difference between transitional and palliative care?
Both transitional care and palliative care are designed to help people improve their quality of life, but there are a few key differences. Transitional care provides practical support (medical and non-medical), as well as emotional care for individuals who live with a chronic illness or are recovering from a major medical event such as a heart attack, stroke or debilitating accident. Palliative care is specialized medical care that focuses on providing patients with relief from the symptoms and stress of a serious illness.
How long will Medicare pay for transitional care?
In many cases, Medicare will pay for the first 30 days of transitional care services. Please work closely with your healthcare provider to determine what benefits your loved one has access to in order to offset the cost of transitional care.
Sources:
https://f2fmedical.com/blog/f/what-is-transitional-care-management(Opens in a new window)
https://www.sequencehealth.com/blog/a-guide-to-transitional-care-management(Opens in a new window)
https://www.medicare.gov/coverage/transitional-care-management-services#:~:text=The%20health%20care%20provider%20who's,days%20after%20you%20return%20home(Opens in a new window)