What is Short Term Transitional Care?

Navigating Hospital Stays and Rehabilitation for Parkinsons Patients. This article is part of The Parkinsons Care Compass: A Caregiving Roadmap Guiding Families Through Every Stage, an educational series presented by At Your Home Caregiving of Texas. We are honored to walk beside families, offering specialized in-home care solutions to support every step of the Parkinsons journey. Hospital stays are a stressful experience for any family, but for individuals living with Parkinsons disease, hospitalization poses unique challenges that can significantly impact recovery and long-term health. When a Parkinsons patient requires surgery, treatment for complications, or recovery after a fall, family caregivers must act as advocates, organizers, and partners in care. Being prepared and informed is the key to ensuring a safe hospital stay and a smooth transition back home.At Your Home Caregiving of Texas understands these complexities and stands ready to help families through every step of the journey, providing expert support for rehabilitation and home-based recovery.Unique Hospitalization Challenges for Parkinsons PatientsParkinsons disease complicates hospital care in several critical ways: Medication Management: Parkinsons medications must be administered on a strict schedule to manage symptoms effectively. Delays or missed doses can lead to severe motor symptoms, confusion, and even hospitalization complications. Mobility and Fall Risks: Hospital environments are unfamiliar, and Parkinsons patients face an increased risk of falls due to balance issues and muscle rigidity. Cognitive Changes: Hospitalization can sometimes trigger or worsen confusion, memory problems, or delirium, especially in older adults with Parkinsons. Communication Difficulties: Some patients experience soft speech (hypophonia) or facial masking, making it difficult to express needs clearly to hospital staff unfamiliar with Parkinsons care. Being aware of these risks allows families to take a proactive role during the hospital stay, minimizing complications and ensuring the best possible outcome.Preparing for a Hospital Stay: Advocacy and PlanningIf hospitalization is scheduled (for surgery or planned treatments), preparation can make a significant difference:1. Create a Hospital Parkinsons PlanPrepare a simple one-page document outlining your loved ones: Current medications and exact times for administration Mobility limitations and fall risk status Communication needs Cognitive changes or dementia symptoms Preferences for therapy, rehabilitation, and home care after discharge Provide this information to the hospital staff immediately upon admission.2. Bring Medications to the HospitalBring a full list and ideally the actual medications in their original containers. In some hospitals, families can administer Parkinsons medications if theres a risk of delays.3. Assign an AdvocateDesignate a family member or professional caregiver to be present as much as possible, especially during medication times, shift changes, and physician rounds. Having a consistent advocate can prevent critical mistakes and advocate for the patients specialized needs.The Importance of Medication TimingOne of the biggest risks for Parkinsons patients in the hospital is missed or mistimed medications. Parkinsons medications like carbidopa-levodopa must be administered exactly as prescribed, sometimes multiple times a day, to prevent a sudden worsening of motor and non-motor symptoms.Tips for ensuring proper medication administration: Clearly document the medication schedule and insist it be incorporated into the hospitals care orders. Politely but firmly remind nursing staff of the critical importance of on-time dosing. Advocate for medication self-administration if allowed by hospital policy. Watch for any substitutions generic or alternate medications can sometimes affect symptom control. Families should feel empowered to respectfully advocate for their loved ones medical needs. Delay in Parkinsons medication can lead to avoidable setbacks in recovery.Understanding Rehabilitation OptionsAfter hospitalization, rehabilitation is essential for helping Parkinsons patients regain strength, balance, and function. Depending on the situation, rehabilitation may occur in: Inpatient Rehabilitation Facilities (IRFs): Specialized centers offering intensive physical, occupational, and speech therapy. Skilled Nursing Facilities (SNFs): Short-term stays focused on medical monitoring and therapy. Home-Based Rehabilitation: Therapy provided at home, which may be the best option for patients with significant mobility challenges or those at high risk of hospital-acquired infections. At Your Home Caregiving of Texas partners with rehabilitation therapists to support continuity of care at home, ensuring that exercises, safety measures, and care plans are followed consistently.Key Rehabilitation Goals for Parkinsons Patients Improving strength and flexibility Reducing fall risk through balance and gait training Enhancing fine motor skills (handwriting, eating, dressing) Improving swallowing and speech if affected Maintaining independence as much as possible Early rehabilitation after hospitalization is crucial for Parkinsons patients. Without it, the risk of decline, injury, and readmission significantly increases.Transitioning Safely Back HomeThe transition from hospital to home is a vulnerable time. Planning ahead is critical to prevent setbacks.Steps for a Successful Transition: Arrange Home Care Services Early: Schedule in-home caregiving services to assist with mobility, medication reminders, and personal care. Conduct a Home Safety Evaluation: Adapt the home environment to minimize fall risks remove tripping hazards, install grab bars, ensure proper lighting, and use assistive devices. Coordinate Medication Management: Update prescriptions, confirm medication supply, and create a clear medication schedule. Schedule Follow-Up Appointments: Ensure post-discharge physician and therapy visits are scheduled before leaving the hospital. Implement a Rehabilitation Plan: Continue physical therapy and exercise routines at home, guided by professional caregivers and therapists. At Your Home Caregiving of Texas specializes in providing comprehensive transitional care for Parkinsons patients. Our caregivers work alongside families and healthcare professionals to ensure that recovery continues safely and effectively at home.How At Your Home Caregiving of Texas Supports RecoveryFamilies managing Parkinsons care dont have to do it alone. Our services are designed to ease the burden of post-hospitalization recovery by providing: Personalized Care Plans: Tailored to the individuals stage of Parkinsons and rehabilitation needs. Medication Reminders and Assistance: Helping maintain the critical medication schedule. Mobility Support: Assisting with walking, transferring, and exercises to rebuild strength and prevent falls. Nutrition and Meal Support: Preparing nutritious meals that support energy and healing. Companionship and Emotional Support: Reducing anxiety, confusion, and isolation during the recovery process. Coordination with Healthcare Providers: Keeping families informed and ensuring therapy recommendations are carried out at home. We work hard to create an environment where patients can heal comfortably, maintain dignity, and reduce the risk of hospital readmission.Final ThoughtsHospital stays are never easy, especially when Parkinsons disease adds another layer of complexity. But with the right preparation, strong advocacy, and a smooth rehabilitation plan, families can help their loved ones achieve the best possible recovery.At Your Home Caregiving of Texas stands beside you every step of the way from hospital bedside to a safe and healing home environment. Our specialized Parkinsons care services ensure that patients get the compassionate, expert support they need to regain strength, confidence, and independence.When its time to transition home after hospitalization, trust At Your Home Caregiving of Texas to be your partner in care and recovery. At Your Home Caregiving of Texas is proud to support families living with Parkinsons disease through compassionate, expert care. For more resources and personalized caregiving solutions, explore the full Parkinsons Care Compass series or contact us today at 469-830-8414. Together, we can create a safer, stronger path to recovery one step at a time.  If someone you care about is facing the challenges of Parkinson's, know that you're not alonewe're always here to help.                                          

In health care settings, the body gets medical attention, but the mind and soul matter, too. Older adults in medical care face a battery of health questions, but too often the most consequential one goes unasked and unanswered: What does a good day look like for you today?Medicare requires people to receive a spiritual assessment within their first five days of admission into hospice. Many states allow a nurse to conduct the initial spiritual assessment, but I think it helps both the person and the health care provider for the assessment to be done with someone who has theological training. Many have been certified in clinical pastoral education, or CPE. Nurses can get so focused on the technical to-do lists of medical work  the measurements, the tests, the drug regimens that it can be hard to make time for the issues that matter most to the living human, namely, their happiness, peace and contentment.  As a spiritual care provider with 17 years in senior care facilities, and as a chaplain in the Army National Guard and Air Force National Guard, I have counseled hundreds of people in the final days of their lives.  For older adults and their families, one of the most valuable resources is also little-known a Medicare option that provides spiritual counseling for people in hospice. Longing for ConversationToo often older adults in care are being talked at, not listened to. Many times, I've found that people in the last chapter of life want to discuss their path to the end more than their medical professionals and, especially, more than their loved ones.  It often helps to have that discussion with a professional who is trained to hear them, and, if requested, to comfort and advise them.  RecommendedOpinion: Why I Went on Hospice Even Though I'm Not Dying | Personal PerspectivesThe code of ethics for the leading chaplain and spiritual care associations all prohibit proselytizing. A spiritual care provider should be able to work with someone on their own terms, no matter their beliefs. The United States may be turning more secular, but the fact remains that older adults are the most faith-affiliated of any demographic age group.This initial spiritual meeting is likely to be about the basics: Is the person religious? What is their support system? Will a certain faith-based ritual bring meaning or comfort? Do they have a preferred faith leader? Or is a secular discussion a better fit for the person's beliefs? 

One Sunday morning in early August, Irene woke up with a badly swollen knee. She thought about waiting until Monday to call her Lifespark Nurse Practitioner but was afraid that bacteria from an infected tooth had migrated to her artificial knee joint, something her orthopedic surgeon had warned her about. If left untreated, an infected joint could require additional surgeries, which is why she had taken prophylactic antibiotics before and after a recent dental procedure.The last thing Irene, 74, wanted was another surgery, but based on previous emergency room visits, she dreaded the thought of going to the ER. Youre sitting for hours next to people who are sick with the flu or COVID, when youre already not feeling well yourself, she said. The doctors are regular GPs [general practitioners] so theyd probably just run some tests and send me home with antibiotics, which Im already taking. She was also concerned about the $100 co-pay, adding that she lives in low-income housing and has limited financial resources.Instead, Irene called Urgent Response Services, Lifesparks 24-hour nurse triage line.Convenient, efficient, and trustedAs a member of Lifespark COMPLETE (LSC), Irene qualified for Urgent Response Services which provides acute-level care for members in their homes. Within minutes, Leah Castle, RN, BSN, Mobile Urgent Responder, was on her way, getting briefed by the triage nurse on Irenes concerns.Once at Irenes home, Leah logged onto the secure portal to access key client information, including Irenes health history, medications, allergies, support system, financial considerations, contingency plans, and goals of care. Having this level of detail at our fingertips helps us make more accurate, more efficient assessments, she said. It also gives us a more complete picture of the member, so we can offer recommendations that align with their goals and lifestyle.After taking Irenes vitals, she drew some blood, took a photo of the worrisome knee, and talked through her findings with the on-call provider. They were both confident that it wasnt a bacterial infection but would wait for the lab results for confirmation. Leah sent a note to Irenes COMPLETE team to schedule a follow-up for the next week. In the meantime, Irene was to continue the antibiotics, take a Tylenol every six hours, ice her knee, and keep the leg elevated as much as possible.Leah dropped off the blood samples at the hospital lab for processing, and in less than two hours, the on-call physician had the results. Leah called Irene to let her know that the labs were negative for systemic infection and that her inflammatory markers were within normal range.Irene was relieved. This was so much better than going to the ER, she said.Rule-outs and rule-insIn Leahs experience, older adults often go to the ER to make sure theres nothing seriously wrong. In fact, studies show that roughly 32% of hospital ER visits are non-urgent and unnecessary. As a Mobile Urgent Responder, shes able to rule out those non-emergencies, efficiently and effectively, from the persons home.That was the case with Irene: shes had both knees replaced and was very concerned that shed need more surgery, Leah said. We were able to put her at ease and assure her that we would continue to monitor and manage her symptoms from home. If there is something to be concerned about, Leah added, the Mobile Urgent Response team is able rule in the need for emergency care.Building on career experienceHaving the confidence to make quick, accurate assessments and communicate them to Lifesparks medical experts comes from her diverse career background. One of Leahs first nursing jobs was on a cardiac step-down unit, a fast-paced, intense environment where the nurses were constantly working with different physicians and therapists. I learned how to quickly build trusting relationships with the providers and also with families during some of the darkest moments of their lives, she said.Leah said she grew professionally in that environment, gaining skills and knowledge that prepared her for her next job, at a long-term acute care hospital. The individuals she cared for had complex diagnoses and illnesses, such as extensive wounds, traumatic brain injury, chronic kidney disease, and respiratory failure. Patients were here for two to six months or more, many of them on ventilators and feeding tubes, so I got to know their families and learned how to support them, too, she said.In 2017, Leah joined Lifespark Community Home Care as their first on-call nurse. Coming into the Home Care setting with my background was powerful, because I knew what my clients had just walked out of, whether that was the hospital or rehab, and now I could help them stay healthy at home, she said.Seven years later, she was recruited for Lifesparks Mobile Urgent Response team. I feel like each step in my career has prepared me for the next one, and now, as a Mobile Urgent Responder, I can be the eyes and ears of our providers in the home, she said. I can also bring care and compassion and empathy to our members, so they feel confident in the care were providing.Benefits of early interventionThe Mobile Urgent Response team has been most successful when members call the triage line before their symptoms progress to a critical level. The team has been able to treat early symptoms of congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) in the home, often with a short-term medication adjustment. However, if a CHF or COPD exacerbation isnt treated, the client would likely need to be hospitalized for IV therapy and increased respiratory support. Recently, Leah collaborated with the on-call provider to diagnose a painful ear infection that had developed quickly. The physician faxed a prescription for antibiotics to the clients pharmacy which they were able to pick up and start taking that same day.Its really fulfilling and rewarding to be able to offer this service to our members and their families who want to be supportive but cant always be there in person, Leah said. Theyre in good hands with Lifespark.To learn how Lifespark helps seniors stay healthy at home, visit Lifespark.com or call 952-345-8770.