Has your loved one recently been discharged from a hospital, after a long period? They may need transitional care support to bridge between the medical facility and their place of residence. Transitional care coordinators can provide assistance to clients transitioning to rehabilitation facilities, skilled nursing facilities, or to their home. Having a transitional care support team in place will ensure that your loved one receives attentive, coordinated care; Caring People’s pro-active approach to the process helps our Transitional Care Coordinators seamlessly integrate into the patient care team. Our transitional care program is an extension of our in-home elderly care services. We focus on providing free rehabilitative care services to our clients, based on Dr. Eric Coleman Model of Care Transitions Structure, which emphasizes establishing rapport with the client, engaging in continuous contact, and providing individualized transitional care coaching. We have a team of transitional care coaches on staff that has years of experience helping clients and their families navigate the system.

Transitional Care Management as an Intervention

Our transitional care intervention services contribute to reducing the likelihood of our client is being readmitted into the hospital, thereby saving costs and stress. Transitional care intervention is very helpful for improving outcomes for clients that require management of chronic conditions. Clients who receive assistance with the transition from the hospital to the home are not only less likely to readmitted, but they also have higher satisfaction rates, greater improved health, and an increased quality of life. Assistance from a transitional care nurse can help to address the deteriorating effects of chronic diseases by serving as a preventative effort. Our client’s vitals are closely monitored, any unusual manifestations of the disease are documented and referred and emergency procedures in case any adverse effects occur. When individuals are readmitted to the hospital, it can become a significant financial burden as well as add to the family’s already high-level of stress, therefore having adequate transitional care program guidelines in place can help calm some fears.

Our transitional care programs are designed to address some of the following challenges, such as:

Focus on Recovery, We are Your Advocate

The purpose of the transitional care model is to provide a clear set of program guidelines for healthcare organizations to use to ensure that care is properly coordinated and there is no harm to the client. The extremely engaging process results in very efficient transitional care for the elderly by implementing a regimen of constant follow-ups, reassessment, and evaluative techniques for effective care. The transitional care model is about providing a seamless move from the hospital setting where the acute and life-threatening condition was resolved to a comfortable environment for where the client can focus on fully recovering. Transitional care coaches work as an advocate on behalf of the client to coordinate care with of other healthcare entities, and can serve as intermediator for families who need updates about their loved one’s condition. To work effectively, transitional care management requires well-trained transitional care nurses and coaches, established transitional care program guidelines, and a transitional care model of hospital discharge protocols. Caring People has an experienced team that works under clear guidelines to provide the best possible. We want our clients to focus on getting better, and we will take care of the rest.

Our Empowering Transitional Care Management Process

Our well-designed process, based on Coleman’s Care Transition Model, requires intense planning and analysis of the needs of our clients; we work families and clients to develop transitional care management and interventions. Our transitional care model is rooted in addressing the unique requirements of the client, by engaging in a collaborative needs assessment process. We begin by having one of our transitional care coaches meet with the client as an introductory meeting at the hospital or long-term care facility; we want to establish rapport with our clients immediately. Next, we schedule home visits with the client within 24-72 hours of their discharge to establish personal goals for recovery; our transitional care coaches provide medication management support, identify red flags, and review the factors that led to the initial hospital admission. The goal of our transitional care coaches is to work with the client to engage in behavioral health change. We follow up with a minimum of 3 or more phone calls per week to make sure that the client stays on track. Our goal is to keep clients engaged, motivated, and empowered to change.

We have designed our process with a holistic view of the following benefits to clients:


Recovering at home makes transitional care effective at putting a sense of confidence and faith that allows improved healing. The transitional care model’s client-centered approach allows the client to have a voice as of how their care is delivered and can be improved.

We believe that the demand for transitional care services will continue to increase in the coming years as more and more elderly live longer; these seniors want elder care services that allow them to remain independent and help to clients recover faster. Transitional care, therefore, combines the best of both worlds by merging excellent hospital care with the familiarity of the home environment. The transitional care intervention program is a free service for Caring People’s clients; it allows them to achieve their personal health goals while improving their functional recovery and preventing a hospital readmission.