What is Transitional Care?

When seniors spend time in the hospital, they are often not ready to live independently immediately after their discharge. Healthcare providers are increasingly aware that a transitional care program can help create an effective continuity of care. Assistance in making a transition from hospital to home can prevent seniors from getting sick or injured following their hospital stay, making recovery time quicker and preventing rehospitalization.

What Is Transitional Care?

Transitional care is a set of services designed to help patients regain health and function as they move from one setting to another – most often from hospital to home. It is often provided in a nursing home setting, but unlike some other forms of nursing home care, transitional care is designed to be temporary. Its goal is to give patients the support they need to return home safely. Transitional care can include treatments such as physical therapy, counseling, and medication management.

Who Needs Transitional Care?

Many seniors who are hospitalized for a chronic illness or a major medical event have more successful outcomes when they receive transitional care before heading home. Some of the patients who benefit most from transitional care include:

• Patients with chronic illnesses like congestive heart failure or chronic obstructive pulmonary disease (COPD);
• Patients who are weakened or temporarily disabled following an acute medical condition or surgery; and
• Patients living with a disability caused by a medical event, such as stroke survivors.

What Services Does Transitional Care Involve?

The primary goal of transitional care is to put patients on the road to independence and self-care, and to avoid rehospitalization. Some of the most valuable services provided by a transitional care facility include:

• Monitoring – The patient’s overall condition is observed, with a focus on frequent problems or potential issues.
• Medication management – According to the National Institutes of Health, medication errors are one of the biggest problems in the period following a hospital stay, and can create major setbacks in the recovery process for seniors. Transitional care providers help patients understand and follow proper medication protocols in order to avoid dangerous mistakes.
• Occupational therapy – To help patients reacquire basic skills, occupational therapy is key. Occupational therapists can re-teach patients everyday tasks like eating, bathing, and grooming, and can help them adapt to new challenges like using a walker or modifying movement following surgery.
• Physical therapy – Many patients need physical therapy to regain strength and mobility after hospitalization.
• Support – By encouraging and educating caregivers, transitional care providers can make the transition from hospital to home smoother and safer for patients.

Transitional Care at Evergreen Health & Rehab

Transitional care is an important component of the services provided at Evergreen Health & Rehab. Our short- term rehab program allows us to ensure a seamless continuum of care and a successful return home. We focus on helping patients regain strength and relearn basic tasks so that they can be confident living independently again.

Along with giving patients and family members the peace of mind of a medically-supervised recovery period, our staff strives to make sure that patients are mentally and physically prepared to go home. Experts say that nurses are at the core of a successful transitional care program, and we couldn’t agree more. In addition to compassionate nursing, our program includes top-quality physical and occupational therapists who ensure that patients are ready to go home on every level.

At Evergreen, the transition does not end when the patient leaves our doors. Our staff members may conduct home visits when a patient exits the program to suggest changes, accommodations, and precautions. Our goal is to make going home safer and easier.

Transitional Care: An Important Step for Recovery

Rehospitalization is a serious topic in the medical community. Providers want patients to return to safe and functional lives at home – instead of getting stuck in a revolving door of hospital stays. High-quality transitional care guides patients on the road to recovery and self-sufficiency, keeping them out of the hospital and getting them back home – where they belong.

At Evergreen, we make a patient’s continuum of care our priority. Our transitional care program is tailored to meet the needs of each patient, and we offer both short- and long-term rehab services in-house so that every therapy is convenient and accessible. With a warm and inviting atmosphere, we treat our patients like family, helping them on the road to recovery and independence.