Transitional Care

What is Transitional Care?

Transitional Care is a service that helps patients move safely and smoothly from one care setting to another, most commonly from the hospital to a skilled nursing facility or your home. It’s designed to provide extra support during this critical recovery period.

When would I use this service?

You would use this service following a stay at a hospital, an emergency room visit or a skilled nursing facility. The goal is to ensure your transition back home is as safe and stress-free as possible.

Who will be helping me during my transition?

You will be supported by our Transitional Care team, often led by a Transitional Care Manager. They are specialists in coordinating all the details of your care after a hospital stay to ensure nothing falls through the cracks.

How does the Transitional Care process work?

The process often starts while you are still in the hospital. Your Transitional Care Manager will coordinate with the staff there, review your discharge plan with you, and then stay in close contact once you are home to make sure your recovery is on track.

Why is this type of care so important?

The 30 days after a hospital stay are a vulnerable time when complications can occur. Transitional Care is important because it helps prevent common problems like medication errors or missed follow-up appointments, reducing your risk of being readmitted to the hospital.

What specific support does the team provide?

Your Transitional Care team can help with a variety of tasks, including:

• Scheduling necessary follow-up appointments.
• Reviewing and helping you understand new medications.
• Arranging for any in-home services or medical equipment you need.
• Answering your questions and connecting you with resources.

Is this service included as part of my care?

If you are being discharged from a hospital or skilled nursing facility, discuss your eligibility for this service with your primary care provider to ensure the safest and smoothest possible recovery.