Transitional Care

How many times have you or your loved one been hospitalized and caught yourself wondering, “Well why didn’t my doctor tell them that?”  The ultimate goal is to get you stable enough to function in your own home either as you once did, or with the assistance of home health care professionals, such as Total Home Health.  Transitional care is a set of actions that is designed to ensure coordination and continuity of health care as clients transfer between different locations or different levels of care within the same location.  These locations could range from hospitals, to the client’s home, to their doctor’s office, and to the long-term care facility. 

The moment you are admitted into a health care facility your discharge planning begins and it will continue throughout your stay.  Transitional care planning is always client-centered and includes all members of the interdisciplinary team that will be involved in your care.  In order to keep up to date with client progress, ongoing consultation with members of the client care team and reassessment of the client’s changing medical functional, social, and cognitive capabilities will be carried out by Total Home Health professionals.  Clients and their families are always involved in decision-making processes and their opinions are highly valued.  Health care professionals will always inform clients and their families of any resources that are available in the community to work toward transitioning the client back into the community once they are stabilized.

Transitional care is based on a comprehensive care plan and the availability of the health care professionals who are highly-skilled in chronic care, and who have up to date information about the client’s goals, preferences, and clinical status.  It includes patient and family education and coordination among all the health care professionals involved in all levels of client care so that nothing goes unnoticed.  Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for individuals with complex care needs.  Following are some key factors in transitional care planning that you should be familiar with:

ü  Transitional care planning considers all aspects of your well-being, including your medical, physical, cognitive, economic and emotional strengths and abilities as well as your available support system.

ü  An assessment of your level of functioning prior to your admission will be carried out to provide insight into resources available after discharge.

ü  Your opinions, along with those in your support system will be valued and involved in decision-making to ensure your satisfaction with your care and allow you to be more in control of your condition.

ü  You and your family will be given the chance to select the providers of your care whenever possible.

Transitional care is also viewed like a bridge that extends between the health care facility you are in and getting you back home.  Care that is provided to you in transition should be excellent and delivered in the most optimal of environments that is dedicated to a quicker recovery for you in order to return you home as quickly as possible. 

Clients should always get the best possible care during their most vulnerable times if their health is compromised.  Included in providing the best care is to ensure continuity and that all professionals involved are fully aware of all pertinent information in order to ensure continued progress toward the ultimate goal of getting each client back home.  It is rather difficult to maintain strict continuity of care especially between different health care locations and between different health care professionals.  However, it is very crucial to providing the best care possible and maintaining therapeutic relationships with clients. 

Total Home Health has a program that is right for you and will welcome you home whole-heartedly as the next step in transitioning back to the way you used to be.  Our compassionate and highly skilled staff will be determined to work beside you to provide you with more support and motivation to get back to where you want to be.  The ultimate goal of Total Home Health is to see you in the element of your own home, satisfied, stable, and able to perform daily tasks just like you did before.  Don’t wait, enroll today!