Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities.
Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs. Southwest Center on Aging created the Transitional Care Program to enhance care for chronically ill patients after they leave the hospital or Skilled Nursing Facility. The innovative community outreach program is designed to:
Identify patients with chronic conditions (such as diabetes or hypertension) who are at risk for readmission
Provide them with additional support after they’re discharged
Connect them with the resources they need to stay healthy
Reduce preventable hospital re-admissions
The program is focused on making sure your transition from the hospital or Skilled Nursing Facility to home is smooth and that all your follow-up care needs are addressed. Each patient is contacted within 24-48 hours of discharge by our staff and a provider will be seeing you withing 7-14 days of discharge or sooner as needed. The amount of contact after that is individualized based on patient need.
The Transitional Care Program is intended to ensure that these patients receive the appropriate ongoing care, such as managing special diet needs or prescribed medications. A major benefit of the program is increased coordination of care and communication with the patient’s entire healthcare team about their special needs. Doctors, patients and loved ones trust us to provide seamless care and monitoring when patients are preparing for discharge from the hospital to their home or assisted/independent living facility.
Journal of the American Geriatrics Society. 2003;51(4):556-557.