Planning Ahead for Your Senior's Transitional Care

Sometimes it may not be possible to plan for follow-up care when your senior leaves the hospital.
Accidents and sudden trips to the ER often leave patients and their families confused and overwhelmed – and the last thing you want worry about is not having the right services in place once your loved one has been sent home.
Whether you’ve decided which in-home care services your senior will need in advance or have just recently begun to explore your options, transitional care is an important part of a successful recovery.
Your senior may have had to deal with a traumatic circumstance that led to their hospitalization. They may have undergone surgery or some other invasive procedure and just been prescribed new medications, equipment or instructions for care.
Unfortunately, after experiencing significant health-related events, many patients are not provided with reliable continuity of care during the transfer from hospital to home.
And because no one system is used by healthcare providers in the U.S., this could mean the difference between hospital readmission and a successful recovery.

What is Transitional Care?

Transitional care is ensuring that a patient has what they need to seamlessly transition from one level of care to another.
The discharge planning process can be handled by either a case manager, social worker or nurse.
Some of the steps involved in transitional care include the patient’s evaluation, meeting with the patient and their loved one, transfer of care, deciding whether further support or care is needed, referral to home health care or other agency, follow up tests and doctor’s appointments.
Transitional care is an important part of the discharge process because it not only helps eliminate confusion about discharge diagnosis, errors involving medications, and lack of follow-up with primary care physicians, but also helps empower caregivers with the knowledge they need to make the best possible choices for their loved one, while keeping the overall costs of healthcare at a minimum.
Here are some things we found at Freedom Home Care to consider before your senior leaves the hospital.

  • What are your loved one’s needs and who can best meet them?
  • How long will the recovery process be and what are their limitations?
  • Does the patient or caregiver know how to manage the medications needed?
  • What indicators to look for of a worsening condition?
  • Do they require home health care services or post-surgery home care?
  • What kind of care can we afford to provide?
  • How much will the insurance company pay for?
  • Will they need special equipment like a wheel chair or feeding tube?
  • How do I administer bandages or treat a wound?
  • How can we lessen the changes of readmission?
  • What resources are available for our situation?

One of the most important elements of transitional recovery involves you.
Becoming an advocate for your loved one not only helps make the transfer from hospital to home easier, it also provides your senior with the best possible chance for a successful recovery.