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Transitional Home Care: Support to Manage the Return Home

6 minute readLast updated February 28, 2024
fact checkedon February 28, 2024
Written by Kevin Ryan, senior living writer
Reviewed by Vicki Demirozu, home care expertVicki Demirozu is a 30-year veteran in the home care industry and founder of Giving Care with Grace, an educational platform aimed at improving the client and caregiver experience.
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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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What is transitional home care?

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]

  • Skilled nursing care, like wound care
  • Medication administration or reminders
  • Monitoring and recording a senior’s recovery progress
  • Meal planning and preparation
  • In-home occupational, physical, or speech therapy
  • Mobility assistance
  • Assistance with activities of daily living (ADLs), like toileting, bathing, and dressing
  • Transportation to appointments

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Benefits of transitional home care

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:

  • Improved communication and care coordination. This is crucial when there are multiple health care providers across different settings. Regular communication ensures nothing is overlooked in a senior’s care plan, both in the hospital and after they’ve been discharged.
  • Adherence to discharge instructions. For example, an in-home nurse or caregiver can make sure prescriptions are filled, organized, and taken correctly while monitoring for side effects. A caregiver might also manage exercise and rest schedules as well as provide help with household tasks.
  • Supervision and companionship. Ensuring that there is someone available even when family members are not offers an extra level of monitoring. This close observation can help detect changes in a senior’s health and provide comfort to loved ones.

Easing the transition from hospital to home for family caregivers

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]

  • Helps to streamline discharge planning
  • Execution of proper post-hospitalization care
  • Increased patient and family caregiver education
  • Improved communication with medical professionals
  • Organization of follow up care

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How to find transitional home care

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.

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  1. 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.

  2. Naylor, M., & Keating, S. A. (2008). Transitional care. The American journal of nursing.

  3. 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.

Meet the Author
Kevin Ryan, senior living writer

Kevin Ryan is a content specialist at A Place for Mom, focused on home care topics that include defining the differences between home care and other senior care types, home care costs, and how to pay. Kevin’s desire to support seniors and their families stems from his previous career as a teacher, plus his experience as a writer and community journalist.

Edited by

Marlena Gates

Reviewed by

Vicki Demirozu, home care expert

The information contained on this page is for informational purposes only and is not intended to constitute medical, legal or financial advice or create a professional relationship between A Place for Mom and the reader. Always seek the advice of your health care provider, attorney or financial advisor with respect to any particular matter, and do not act or refrain from acting on the basis of anything you have read on this site. Links to third-party websites are only for the convenience of the reader; A Place for Mom does not endorse the contents of the third-party sites.

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