Transitional care is intended to provide and promote the safety of patients between levels of health care and across care settings. It is also about getting the right level of care for patients to support their move back to the community.

Seniors with chronic and acute illnesses and those who have gone through an operation come back to their homes and are vulnerable to breakdowns in care, thus have the greatest need for transitional care services to avoid adverse events and rehospitalization. It is also important to have a single point person to ensure continuity of care and keep watch of the patient’s condition.

Family caregivers play a major and most important role in supporting older adults during hospitalization and especially after discharge. They need to be properly communicated with what they need to know during the transition from one care setting to another whether from hospital to rehab or home.

Family caregivers also need a high level of engagement in decision-making about discharge plans and the quality of preparation for the next stage of care, access to essential services, and adequate education on what to expect and need when moving their loved ones home. Caregiving can be rewarding but it imposes a lot of pressure and stress on the family.

Transitional care from professional home care providers can help minimize negative experiences and enhance the ability to support their loved ones at home. Professional caregivers can help ensure continuity of care when discharged from the hospital or rehab to a home care setting but need help with mobility, personal care, and close monitoring. Professional caregivers can help assess and communicate any changes in the patient’s condition and also support their emotional needs.

To know more about different home care plans are listed here: Home Care Services

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