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Care Transitions

Care Transitions

Why do care transitions matter? Without a structured care transitions plan, about 1 out of every 5 people who transition home after a hospital stay have to go back to the hospital unexpectedly. Studies show that people who follow a structured care transitions plan are much more likely to get better and stay home without having to go back into the hospital.

When a person is being discharged from a hospital or rehab facility to their home, it is called a “care transition.” The term “care transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

For example, a person might see their primary care doctor and then be admitted to a hospital where a hospital physician and nurses take care of them. From the hospital they might go to a skilled nursing facility or an acute rehab facility where different doctors, nurses and therapists take care of them. From there, they might go back home and be seen by a home health nurses and therapists and follow up with their primary care doctor again. Each time they go from one health care setting or provider to another, it is a care transition.

Because going back to the hospital unexpectedly is a big problem, our government has been supporting a lot of research to figure out what are the best things to do to be able to stay home after being in the hospital. That’s good because we now know some specific things to do to help. Also, a lot of people are talking about care transitions, which can be helpful. Unfortunately, some home health agencies are talking a lot about it but not implementing the recommended steps.

We have a care transitions plan that we follow that will give you the best chance of staying home once you get home. We understand how important the hospital is, and we deeply appreciate the amazing care that hospitals provide, but why go back to the hospital unexpectedly if you don’t need to? When you are discharged from the hospital and receive home health services from Advanced RehabTrust, you will have the confidence and peace of mind that comes from knowing that everything that can be done is being done to keep you safe and healthy in your home.

For more information about Care Transitions, please Call Toll Free: 1-866-384-0393.

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