Returning home from the hospital or a skilled nursing facility can be a challenging transition. While seniors may be anticipating a return home, they’re likely in a vulnerable state and require some support to continue their recovery. Transitional home care caregivers oversee a person’s medical and personal care as they move from a care facility back home. This type of care works to make sure that a senior’s needs continue to be met at home. Transitional home care can also help family caregivers understand and manage the care their loved one needs.
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Transitional home care is support provided by caregivers, licensed nurses, or nursing assistants when a person moves from a care setting — like a hospital — back to their home. Transitional care can also be provided in senior living settings like independent living and assisted living communities. This type of home care is usually temporary and occurs after a stay in a hospital, skilled nursing facility, or other type of rehabilitation setting.
Transitional home care includes a specific plan of care to address the senior’s individualized needs. Care plans also provide clear communication between the care facility, the senior and their family, and the home-based caregiver or nursing staff.
A transitional home care plan may include support from several types of care providers. Depending on a senior’s needs, it may also include medical supplies like a wheelchair or walker. Services might include any of the following:[01]
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The primary benefit of transitional home care is that it helps to ensure a continuity of services. It can improve a person’s health and functional outcomes, including a decreased risk of readmission to a hospital.[02]
Seniors are vulnerable to lapses in care when moving from a care facility back home, which may contribute to higher rehospitalization rates among those 65 and older.[01] Having transitional support is critical to a senior’s ongoing recovery. Transitional home care promotes the following benefits:
Managing a senior loved one’s transition home can be an overwhelming prospect for family caregivers. You may be juggling emotions along with your own responsibilities, like a job and other family obligations. The support of a transitional caregiver can be an invaluable source of peace of mind and respite.
Transitional home care plays an important role for family caregivers by offering the following kinds of support:[03]
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If your elderly loved one is anticipating a transfer between a health care facility and home, consider speaking with the facility about their discharge plan. Most hospitals and skilled nursing facilities will recommend home care providers, but you can also opt to find one on your own. A Place for Mom’s Senior Living Advisors offer free guidance and can help connect you with home care agencies in your area that fit your loved one’s needs and budget. They can also help you find senior living facilities, some of which may have their own transitional care staff in place.
Weiss, A., & Jiang, H.J. (2021, July). Overview of clinical conditions with frequent and costly hospital readmissions by payer, 2018. Healthcare Cost and Utilization Project.
Naylor, M., & Keating, S. A. (2008). Transitional care. The American journal of nursing.
Mitchell, S. E., Laurens, V., Weigel, G. M., Hirschman, K. B., Scott, A. M., Nguyen, H. Q., Howard, J. M., Laird, L., Levine, C., Davis, T. C., Gass, B., Shaid, E., Li, J., Williams, M. V., & Jack, B. W. (2018). Care transitions from patient and caregiver perspectives. Annals of family medicine.
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