What Is Transitional Care?

Author

BrightStar Care

For more information about the author, click to view their website: Brightstar Care

Posted on

Jul 19, 2023

Book/Edition

Florida - Southwest

share-this
Share This

Transitional care is an umbrella term that encompasses a range of services designed to help individuals and families make successful transitions from one stage of health care to another. The goal of transitional care is to help individuals manage their health and maintain their independence by providing them with the resources they need as they move through different stages of treatment. Transitional care can be tailored to fit individual needs and includes services such as physical therapy, occupational therapy, social work, nutrition counseling, medication management, and more. Transitional care also includes follow-up visits with primary healthcare providers and specialists.  

Who Is Transitional Care For?  

Moving on from one health care setting to another can be a tricky situation for anyone, and that's where transitional care comes in to play. This type of care provides essential support for people as they navigate their way from a hospital or nursing home back to their home, or even as they move into an assisted living facility. It can be a true lifeline, helping to ease the transition and ensuring that individuals have the proper resources and guidance they need to move forward with confidence in their health and wellness. 

It’s also beneficial for those managing chronic illnesses or major medical events such as strokes or heart attacks because it provides continuity of care during times of change. Additionally, transitional care can be used by caregivers too; caregivers often need assistance in understanding how best to manage their loved one’s condition at home after discharge from the hospital or rehabilitation center.  In short, anyone who needs assistance with creating a plan for transitioning from one form of health-related situation to another can benefit from transitional services.   

At BrightStar Care our team works closely with your medical providers throughout your transition process so that you get the personalized attention you need during this critical time. Our team will coordinate follow-up appointments with all involved parties so that there is continuity between each step in the process, allowing you or your loved one's recovery journey go as smoothly as possible while providing peace of mind for everyone involved.  

Short-Term Transitional Home Care Services Offered by BrightStar 

Our BrightStar Home Care (Opens in a new window) team of registered nurses are dedicated to helping you transition safely back home. With a wide range of in-home services (Opens in a new window), we provide personalized plans that ensure your health needs are met with the utmost care and accuracy. Our team provides for health needs such as: 

  • Chronic Obstructive Pulmonary Disease (COPD) 
  • Diabetes 
  • Heart Attack/AMI (Acute Myocardial Infarction) 
  • Heart Failure 
  • Pneumonia 
  • Post-Operative 
  • Stroke 
  • Therapy for Post-Op or Stroke 

Transitional care management includes multiple services to ensure proper healthcare delivery for patients. It involves obtaining and reviewing patient discharge information, assessing the need for further diagnostic tests and treatments, providing education to the patients and caregivers, establishing referrals to and arranging for community resources, scheduling follow-up visits with various services, and coordinating care with home and community-based clinical service providers.  

A critical aspect of transitional care is the reduction of unnecessary hospital readmissions and medication management. BrightStar Care seeks to make the transfer from hospital to home as seamless and efficient as possible, ensuring patients are comfortable and well taken care of throughout the process. 

BrightStar Care transitional care services are conveniently located around the country (Opens in a new window), allowing you access to the help you or a loved one need when you need it most.  

In-Home Transitional Care Services 

When it comes to transitional care services, there are many benefits to receiving care in the home. One major benefit is the convenience it provides. With in-home transitional care services, the individual and their family members don't have to worry about the potentially hefty cost of a nursing home or rehab facility. They also don't have to worry about transportation to and from the hospital or rehab center, as they can receive care right where they live. This can be especially important for individuals who have limited mobility or who have difficulty getting around. 

Another benefit of in-home transitional care services is the level of personalization that can be provided. At BrightStar Care, we understand that no two individuals are the same, and their care needs vary. Through our transitional care services, individuals receive personalized care that addresses their specific needs, including personal services such as light housekeeping, meal prep, and medication management. This level of customization allows individuals to receive the care they truly need, promoting a faster and more comfortable transition back to home and routine. 

In addition, receiving care in the home can be less stressful for both the individual and their loved ones. Receiving care in the home allows the individual to have greater control over their surroundings, which can be especially important for those who may have anxiety or other conditions that can be exacerbated by an unfamiliar environment. Similarly, this can provide much-needed peace of mind for family members, who can rest assured that their loved one is in a familiar, comfortable environment that promotes healing. 
 

Choose BrightStar Care Today for Your Transitional Care Services! 

Transitioning between different stages of health-related situations can be overwhelming without proper guidance and support; this is where transitional services come into play! At BrightStar Care® (Opens in a new window) our team works closely with you or your loved one during this critical time so that you receive personalized attention every step along your journey back home! With our help, you can ensure that your recovery goes as smoothly as possible while providing peace of mind for everyone involved! Contact us today (Opens in a new window) if you have any questions about our transitional services! We look forward to hearing from you soon!  

 

Other Articles You May Like

Hospice Provides Post-Discharge Support That Sepsis Patients Need

By Faith Protsman, MD, Regional Medical Director, VITAS HealthcareTwo recent studies highlight how sepsis impact often extends well beyond the acute event that led to a patients hospitalization. The studies emphasize two particular points that should inform physicians and clinicians as they consider referring these patients to specialized care: Medicare patient data gathered between 2012-2017 shows that sepsis patients face considerably poorer health outcomes following hospital discharge when compared to non-sepsis patients, including elevated risk for death and increased use of advanced healthcare services. Sepsis survivors exhibit strong indicators of persistent inflammation and immunosuppression for up to a year after hospital discharge, increasing their risk of readmission or death. Both studies indicate a significantly elevated risk of death among sepsis patients after they have been discharged and ostensibly cured. Of course, sepsis patientsparticularly those of the Medicare cohort, who are largely of advanced agerarely leave the hospital in better condition than they entered.The Yende study, in particular, shows that neuroendocrine and inflammatory responses to sepsis can continue long after the patient survives a septic episode. For patients with advanced or chronic diseasesas was the case with nearly 78% of participants in the studythese biomarkers are associated with decline.Post-sepsis Discharge: A Critical JunctureIn many cases, these individuals life expectancies upon discharge will be less than six months. This is a critical juncture: While comfort-focused hospice care could provide an ideal source of support for the eligible patient, their family, and their caregiver(s), most sepsis patients are simply sent home without even a discussion about palliative end-of-life care and its benefits.Frankly, such an oversight is a disservice to everyone involved. The sepsis patient is left with physical and/or cognitive dysfunction, often without significant options for symptom management. Their partner or family will either need to assume caregiving duties or turn to costly private services. And the physician and hospital staff will likely see the patient again following another acute event, a readmission that impacts performance scores, strains resources, and unnecessarily fills beds.By no means do I intend to lay the blame for these unfortunate circumstances on physicians. Timely hospice referrals require ongoing education about end-of-life care, and open, ongoing communication between hospice providers and referral sources.More Help: How to Talk About Hospice Care >Those of us in hospice are working hard to bridge the gap, but even as our healthcare system transitions to a value-based model, the mentality of fee-for-service still permeates our nations acute-care facilities, and many hospitalists see a discharge home as a success.Hospice: A New Way Of Judging SuccessIn hospice, we judge our successes on the patients quality of life and the fulfillment of their goals and wishes near lifes end. Usually, that means going home with 24/7 support from an interdisciplinary hospice team. Whether home is a traditional residence, an assisted living facility, or nursing home, the hospice team will assist caregivers (and/or facility staff) with direct clinical care and education, integrative services, bereavement support, and delivery of medication, equipment, and supplies.In other cases, improving quality of life means remaining in a general inpatient setting with hospice support, taking the burden off hospital staff until the patient is able to transition home or until the patient dies. Hospice offers complex modalities in any setting, so patients who would otherwise be confined to an ICU can usually return home to be among loved ones.With support from hospice, a sepsis patient and their family are more likely to report higher satisfaction of care and greater quality of life. The patients emotional and spiritual needs can be met alongside their physical needs, thanks to care from chaplains, social workers, music and massage therapists, and other integrative specialists. Finally, the patient is more likely to die at home, surrounded by loved ones, rather than in the hospital.Because sepsis is most common in patients with advanced or chronic diseases that indicate hospice eligibility, acute incidences of sepsis should always trigger a hospice eligibility assessment. We owe it to our patients, their loved ones, and our colleagues in healthcare, all of whom can benefit from the support that timely end-of-life care offers. 

Making Daily Living Easier: Senior Home Organization Done with Love

As life evolves, so do our needs at home. For seniors, navigating daily life in a cluttered or disorganized space can be overwhelming and even unsafe. Creating a home environment that is both functional and nurturing is an act of love and respect. At A Call to Order Professional Organizers, we specialize in transforming homes into spaces that prioritize comfort, safety, and joy. With thoughtful adjustments and a touch of care, senior home organization becomes a gateway to easier living and peace of mind.The Impact of Thoughtful Home Organization on SeniorsA well-organized home offers far more than convenience. It promotes safety, independence, and emotional well-being, ensuring seniors feel confident and comfortable in their surroundings.Why Senior Home Organization Matters:Enhances SafetyReducing clutter and organizing essentials minimizes risks like trips and falls, which are common in senior households.Boosts IndependenceAn organized home allows seniors to find and access what they need without assistance, fostering a sense of autonomy.Reduces StressA tidy, harmonious space alleviates feelings of overwhelm and creates a calming atmosphere.Preserves MemoriesThoughtfully arranging sentimental items honors cherished memories while maintaining an orderly space.Practical Considerations:Conduct a home walkthrough to identify problem areas that need decluttering or reorganizing.Include seniors in the decision-making process to ensure the space aligns with their preferences and habits.Focus on high-traffic areas like kitchens, bathrooms, and living rooms where safety and accessibility are paramount.Tips for Senior Home Organization with Love and CareCreating a senior-friendly home doesnt require drastic changes. With a compassionate approach and practical strategies, even small adjustments can make a big difference.Tips for Organizing with Love:Declutter with CompassionWork alongside the senior to sort through belongings. Encourage them to share stories about sentimental items, and help them decide what to keep, donate, or discard.Prioritize AccessibilityArrange frequently used items at waist level to avoid bending or reaching. Use open shelving or labeled containers for easy access.Incorporate Safety FeaturesAdd non-slip mats in bathrooms, secure loose rugs, and ensure lighting is bright and consistent throughout the home.Create Functional ZonesDesignate specific areas for activities like reading, crafting, or relaxing. Keep supplies for each activity neatly organized within reach.Use Simple SystemsImplement straightforward organizational tools such as color-coded bins or daily planners to keep track of medications, appointments, and important documents.A Loving Touch:Personalize the space with photos, favorite colors, and cozy elements like soft throws or pillows.Display sentimental items in a way thats both organized and meaningful, such as a memory shelf or photo collage.Organizing a seniors home is about more than tidinessits about creating a space that supports their well-being and celebrates their life. At A Call to Order Professional Organizers, we approach every project with empathy and a commitment to making daily living easier for seniors and their families. By combining practical solutions with a heartfelt touch, we turn homes into havens where seniors can thrive. Lets make 2025 a year of love, care, and beautifully organized spaces for the ones who matter most.

Moving Toward Comfort: Senior Moves That Feel Like Coming Home by A Call to Order Professional Organizers

For seniors, the prospect of moving can bring a whirlwind of emotionsexcitement about new beginnings and anxiety about leaving behind a cherished home. At A Call to Order, we understand that a move is not just about relocating belongings; its about transitioning to a space that feels like home again. Our mission is to help seniors navigate this significant life change with compassion, care, and a focus on comfort. In this blog, well explore how to make a senior move an experience that truly feels like coming home, filled with warmth, connection, and peace of mind.Understanding the Emotional Landscape of MovingMoving can evoke a series of feelingsnostalgia, anxiety, and even joy. The home is a tapestry of memories, and leaving it can feel daunting. Here are some emotions seniors may experience during this transition:Nostalgia: Each corner of the home holds memories of special momentsbirthdays, anniversaries, quiet evenings with loved ones. The thought of leaving these behind can be heartbreaking.Anxiety: The unknowns of a new environment can lead to significant worry. Seniors often fear the challenges of adjusting to a new community, making friends, or navigating different routines.Overwhelm: The logistics of sorting through a lifetime of belongings can be daunting. The sheer volume of items can feel chaotic, leading to stress and confusion about where to start.At A Call to Order, we recognize these feelings and strive to create a moving experience that addresses these emotions head-on. With our compassionate, personalized approach, we help seniors build connections in their new space while honoring the memories they are leaving behind.Tips for Creating a Comfortable MoveMoving can be a comforting experience rather than a source of stress. Here are some actionable tips to ensure that every senior move feels like the start of a new chapter filled with warmth and comfort:1. Start with a Memory JourneyBefore diving into packing, take a moment to reflect on special memories associated with the home. Create a memory wall or scrapbook that showcases photographs and stories connected to various aspects of life in the house. Seniors can celebrate the good times and recognize that while the objects may leave, the memories can be cherished forever. This emotional exercise can help bring a sense of closure and gratitude before transitioning.2. Involve Loved OnesEncourage seniors to involve family members in the moving process. Having loved ones by their side can turn what might feel like a daunting task into an opportunity for connection. Together, they can sift through belongings, share stories, and decide what to keep, donate, or discard. This shared experience fosters a sense of community and reminds seniors that they have support during significant life changes.3. Prioritize the EssentialsPacking can quickly become overwhelming, so its crucial to approach it with a clear plan. Help seniors identify the items that are truly essential for their new spacethose that provide comfort and utility. Consider creating a must-have box that includes favorite blankets, important documents, treasured photos, and everyday essentials. Having personal items at their fingertips when they move in can instantly make the new space feel familiar and welcoming.4. Visualize the New SpaceEncourage seniors to visualize how their belongings will fit into their new home. Create a floor plan that includes familiar pieces of furniture from their previous home. This exercise allows them to envision what their new living space will look like and where treasured items will go. Visualization helps ease anxiety and enhances excitement about setting up a new sanctuary.5. Honor the TransitionTransitioning possessions doesnt have to mean letting go of cherished belongings. Suggest creating a comfort box filled with items that evoke positive memoriesfamily heirlooms, comforting blankets, or beloved books. This box can go to the new home and serve as a reminder of the rich tapestry of love and history that has been woven throughout their lives.6. Seek Professional SupportPartnering with professional organizers, like A Call to Order, can significantly ease the moving process for seniors. Our compassionate team specializes in senior moves, understanding the emotional nuances and logistical challenges that come with them. We provide hands-on support in organizing, packing, and unpacking, ensuring we honor the past while creating a comfortable and welcoming new atmosphere. Our aim is to transform the logistical burden into an organized and positive experience.Embracing a New ChapterAt A Call to Order, we believe that every move should be a celebration of new beginningsa fresh start filled with warmth and familiarity. By approaching the transition with love and compassion, we support seniors in creating a new home that feels just as comfortable as the old one. Every box unpacked is a step forward, every memory honored is a stepping stone, and every moment embraced is a reminder that no matter where we go, love is what truly makes a house a home.If you or a loved one is preparing for a move, let A Call to Order guide you through the process with care. Together, we can ensure that your journey toward comfort is filled with hope, connection, and the essence of home, making it feel like coming home again.

Local Services By This Author

BrightStar Care of Naples & Ft. Myers

Non-Medical 2545 Northbrooke Plaza Drive, Naples, Florida, 34119

BrightStar Care is a leading in-home care agency that has been serving Lee and Collier counties since 2006. With a wealth of experience spanning 18 years, we have become a trusted name in providing compassionate and professional care to individuals within the comfort of their own homes. At BrightStar Care, we offer a wide range of services to meet the diverse needs of our clients, including both Medical and Non-Medical Care. Our non-medical care, also referred to as non-skilled care, includes assistance with IADLs such as transportation, meal preparation, medication reminders light housekeeping, laundry and ADLs such as assistance with personal care needs, transferring, and feeding. Our medical care, also referred to as skilled care, services encompass more complex medical needs with care being provided by an LPN or RN. Some of the Skilled services we offer include case management, medication management, medication administration and teaching, wound care and wound vac, disease education and monitoring, IV treatments and line maintenance, catheter and ostomy care, home safety evaluation and much more. In addition to non-skilled and skilled care, BrightStar Care takes pride in offering physical therapy (PT) and occupational therapy (OT) services. Our team of licensed therapists collaborates closely with clients to develop personalized treatment plans, aiding in the restoration of independence, improvement of mobility, and enhancement of overall quality of life. Another aspect that sets BrightStar Care apart is our medical staffing services. We understand the significance of having qualified and reliable healthcare professionals in various settings, such as hospitals, clinics, and long-term care facilities. Through our medical staffing solutions, we provide healthcare organizations with certified nursing assistants, skilled nurses, therapists, and other healthcare professionals on either a temporary or permanent basis. As an organization, we hold the prestigious Joint Commission Accreditation, which represents the gold standard in healthcare. This accreditation validates our commitment to delivering the highest standard of in-home care through quality and safety. Our dedication to providing top-notch care is further exemplified by our rigorous care team member selection and training processes. We carefully choose and train our care team members to ensure they possess the necessary skills, knowledge, and compassion to provide exceptional care to our clients. Furthermore, our thorough screening process, including background checks, drug testing, and reference verifications, instills peace of mind in our clients. Additionally, all our care team members undergo extensive hands-on training with our Director of Nursing, which includes comprehensive skills review, disease-specific training programs, as well as Dementia Live and our own Alzheimer's training called Bright Connections.  What truly distinguishes us, however, is our genuine commitment to providing personalized care tailored to the unique needs of our clients. Our Rns create a comprehensive personalized plan of cares for each client. We believe in cultivating meaningful relationships with our clients and their families, creating a warm and supportive environment that promotes overall well-being which is why we created our own program called Purposeful Engagements.In recognition of our efforts to provide peace of mind to clients and their families, BrightStar Care has received numerous awards, including the Home Care Pulse awards for Provider of Choice, Employer of Choice, and Leader in Excellence. When it comes to in-home care, BrightStar Care is the agency of choice for those seeking exceptional care, compassion, and support. Our mission is to enhance the lives of our clients, enabling them to live comfortably and independently in their own homes through delivering a higher standard of in home care and providing peace of mind. Having proudly served Lee and Collier counties for over 18 years, we are excited to continue delivering exceptional in-home care services to our community.

BrightStar Care of Naples & Ft Myers

Home Health 2545 Northbrooke Plaza Drive, Naples, Florida, 34119

BrightStar Care is a leading in-home care agency that has been serving Lee and Collier counties since 2006. With a wealth of experience spanning 18 years, we have become a trusted name in providing compassionate and professional care to individuals within the comfort of their own homes. At BrightStar Care, we offer a wide range of services to meet the diverse needs of our clients, including both Medical and Non-Medical Care. Our non-medical care, also referred to as non-skilled care, includes assistance with IADLs such as transportation, meal preparation, medication reminders light housekeeping, laundry and ADLs such as assistance with personal care needs, transferring, and feeding. Our medical care, also referred to as skilled care, services encompass more complex medical needs with care being provided by an LPN or RN. Some of the Skilled services we offer include case management, medication management, medication administration and teaching, wound care and wound vac, disease education and monitoring, IV treatments and line maintenance, catheter and ostomy care, home safety evaluation and much more. In addition to non-skilled and skilled care, BrightStar Care takes pride in offering physical therapy (PT) and occupational therapy (OT) services. Our team of licensed therapists collaborates closely with clients to develop personalized treatment plans, aiding in the restoration of independence, improvement of mobility, and enhancement of overall quality of life. Another aspect that sets BrightStar Care apart is our medical staffing services. We understand the significance of having qualified and reliable healthcare professionals in various settings, such as hospitals, clinics, and long-term care facilities. Through our medical staffing solutions, we provide healthcare organizations with certified nursing assistants, skilled nurses, therapists, and other healthcare professionals on either a temporary or permanent basis. As an organization, we hold the prestigious Joint Commission Accreditation, which represents the gold standard in healthcare. This accreditation validates our commitment to delivering the highest standard of in-home care through quality and safety. Our dedication to providing top-notch care is further exemplified by our rigorous care team member selection and training processes. We carefully choose and train our care team members to ensure they possess the necessary skills, knowledge, and compassion to provide exceptional care to our clients. Furthermore, our thorough screening process, including background checks, drug testing, and reference verifications, instills peace of mind in our clients. Additionally, all our care team members undergo extensive hands-on training with our Director of Nursing, which includes comprehensive skills review, disease-specific training programs, as well as Dementia Live and our own Alzheimer's training called Bright Connections.  What truly distinguishes us, however, is our genuine commitment to providing personalized care tailored to the unique needs of our clients. Our Rns create a comprehensive personalized plan of cares for each client. We believe in cultivating meaningful relationships with our clients and their families, creating a warm and supportive environment that promotes overall well-being which is why we created our own program called Purposeful Engagements.In recognition of our efforts to provide peace of mind to clients and their families, BrightStar Care has received numerous awards, including the Home Care Pulse awards for Provider of Choice, Employer of Choice, and Leader in Excellence. When it comes to in-home care, BrightStar Care is the agency of choice for those seeking exceptional care, compassion, and support. Our mission is to enhance the lives of our clients, enabling them to live comfortably and independently in their own homes through delivering a higher standard of in home care and providing peace of mind. Having proudly served Lee and Collier counties for over 18 years, we are excited to continue delivering exceptional in-home care services to our community.