Care Transitions

Care Transitions

What Does “Care Transitions” Mean?

Care Transitions refers to the coordination and continuity of health care during movement from one healthcare setting to either another or to home and between health care practitioners, and settings as the client’s condition and care needs change during the course of a chronic or acute illness. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. Our Care Navigators are here to help.

Live Well at Home is uniquely qualified to provide transitional care. Our staff consists of Care Coordinators and Care Navigators who can collaborate in providing a Custom Care Plan to meet you or your loved one’s needs.

Our Care Navigators are where the planning begins for your care transition. The Care Navigator will meet with you and your family to discuss the patient’s goals, preferences, and care needs and bring in the appropriate resources to create a smooth transition from a care facility [hospital, skilled, etc.] to home, whether that be your own home, independent or assisted living.

Some of the Transitional Care needs may include:

  • Discussion on durable medical equipment needed at home
  • Caregiver training by a physical therapist to continue rehabilitation exercises
  • Transportation from facility to patient’s home
  • Pick up prescriptions and medical supplies
  • Checking refrigerator for expired food and shopping for new groceries to meet dietary requirements
  • Arranging follow-up appointments and communication with family members or client representatives
  • In-home care

What is a Care Navigator?

The Care Navigator preserves dignity offering clarity and stability at a time when you need it most. We reduce what may be overwhelming decisions and help you make the right decisions about care, caregiving and life transitions.

We identify needs and assess situations

  • We coordinate care related to life, health and home
  • We coordinate transitions
    • From hospital or skilled nursing to:
      • your home to continue your recovery in the comfort of your own home, or an independent or assisted living community
      • in-home care to ease the transition and provide a safe and healthy environment
      • We bridge pre-admission, the hospital or skilled nursing stay and discharge
  • We help provide a better sense of preparation for the care transitions, reducing stress
  • We help build healthier outcomes
  • We
    • Identify needs
    • Make recommendations
    • Identify support needed to help individuals remain at home

How Can Live Well at Home assist with a Care Transition?

Many of the questions that come up when thinking about a discharge from a care community are:

  1. How do I get home?
  2. Who will be there to help me?
  3. Who will pick up my prescriptions?
  4. How will I get groceries?
  5. Will I need help with meal preparation?
  6. Do I need assistance bathing?
  7. Do I need assistance with prescribed exercises?
  8. How long will I need assistance?
  9. Do I need follow-up doctor appointments?

Our Care Navigator can meet you, and your family before you are discharged home to assist in the planning and provide assistance through the hurdles of discharge, rehabilitation and on-going care needs.

What Do I Need to Know to Plan Ahead for a Smooth Care Transition?

Returning home from a hospital stay can result in unexpected challenges for many seniors. Finding themselves back at home after a hospital stay, many older adults struggle to manage their medications and make follow-up doctor’s appointments as well as obtain the physical assistance and in-home support they may require on a temporary basis. As a result, many older adults do not successfully make the transition home and end up returning to the hospital. In fact, one in five Medicare patients are readmitted to a hospital within 30 days after discharge. Studies have shown that nearly half of the readmissions are linked to social problems and lack of access to community resources.

You can help ensure that you or your loved one makes a successful transition home from the hospital if you start planning for your hospital visit before you are admitted for a planned procedure or for unexpected visits. It is wise to start planning for discharge the day of admission. Planning goes a long way to help patients address the questions that arise during the discharge process and make a safe and smooth return home.

Post Hospital or Skilled Nursing

Your Home

Order equipment and supplies

  • Hospital bed?
  • Bed rails?
  • Shower chair?
  • Commode?
  • Oxygen supply?
  • Depends, pads, briefs?
  • Gloves?
  • Wheelchair?
  • Walker?

Will insurance pay for your equipment and supplies?

Health Care Tasks

  • What will you need help with?
  • Will you need assistance with approved exercises?
    • Caregiver may need to be trained by the physical therapist for your personal needs
  • Help with personal hygiene?
  • Are there restrictions in what you can do?
  • Are there symptoms that you must report right away?
  • Is it safe to be alone?

To learn more about Care Transitions please click here »

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