The transitional care model at Caring People Home Healthcare has been implemented to provide a smooth transition from a hospital, rehabilitation center or skilled nursing home to the client’s home. Once on services with Caring People, the transitional care management approach supports the transition by working closely with the patient and family caregiver to provide a more active role in their care.
The transitional care model supports the successful shift from institution centered to a patient centered focus. Transitional care management affords continuity of care when patients are hospitalized and transfer back home. Transitional care for the elderly supports the needs of our senior community by allowing the good care given in the hospital, rehabilitation or skilled nursing home to be maintained once home too. Confusion, frustration, miscommunication often take place after discharge from a hospital, rehabilitation facility or skilled nursing facility and our elders and their caregivers commonly are uncertain what to do next. Ask yourself the following questions and you will know if transitional care management is right for you.
Is the diagnosis clear, what medications have been prescribed, have there been any changes made in medications since the hospitalization, what are the warning signs that led you or your loved one to the hospital, what are the precautions, are test results fully understood, have follow-up appointments been made with the primary care physician or specialist, when will physical therapy, occupational therapy, speech therapy, or wound care begin? Modeling and facilitating new behaviors, skill transfer, and communication strategies help build confidence so our elders and the family caregiver will be able to respond to common problems that arise during transitions. A home visit within 24 to 48 hours of hospitalization, rehabilitation or a skilled nursing home discharge will be conducted and four weekly follow-up phone calls implemented, aiming to increase self-management skills and personal goal attainment for all.
Over the course of 30 days, the Transitional Care Coach listens to and honor the client’s goals, preferences, observations and concerns. The result, an empowered, safe individual with clarity of medical condition. The Transitional Care Model facilitates communication and continuity of care plans across settings empowering and educating clients and caregivers to become more independent. Transitional care for the elderly will lift self-esteem and build confidence allowing the individual to recognize the signs and red flags that precipitated the hospitalization.
There is no cost to you or your loved one for Transitional Care Management at Caring People. The transitional care model will help prevent an unnecessary hospital readmission and lower your healthcare costs.