Transitional Care describes a period of transition from a rehabilitation, hospital or assisted living facility setting, back into the home. After leaving a particular care setting, older patients may not understand how to manage their health care conditions or whom to call if they have a question or if their condition gets worse. Poorly managed transitions can lead to physical and emotional stress for both patients and their caregivers.
Patients that have had around-the-clock care may have difficulty adjusting back to total independence; To address this, ElderCare at Home created the Transitional Care program that utilizes the individualized ElderCare Plan. The Transitional Care program provides caregiver services that help patients complete their journey back to health and independence. Transitional Care services focus on the specific needs of the patient by providing help where needed and giving ample encouragement and motivation for a full recovery back to being independent.
Transitional Care providers receive several specialized training including:
Alzheimer’s, Dementia and Geriatric training. These Certified Nursing Assistants (CNA) and Home Health Aides (HHA) are instructed on proper procedures that focus on healing, such as range of movement exercises and aquatic exercise techniques. The ultimate goal is to prevent patients from returning to the hospital or rehabilitation setting.
ElderCare at Home’s management team is diligent in communications with physicians, the discharging facility, and physical therapists to make sure that the transitional phase goes smoothly and that all physician’s orders are being met. Additionally, the caregivers must report any changes in condition (including improvements) to the office and family so that the patient’s progress back to health can be monitored and evaluated properly. The caregiver’s ultimate goal is to achieve the patient’s highest functioning level of independence, and to have the patient living independently in the place they most want to be.. their own home!