There’s No Place Like Home; Planning Transitional Care

If you are like most, a hospital is the last place you want to call home. We can’t wait to get home to our own beds, our own space, and back to normal.

Many times, transitioning home from an inpatient rehab or hospital setting can bring its own set of challenges; not just for the patient but also the family involved in care. It can be scary and overwhelming to transition home and that’s completely understandable.
1 in 5 seniors are readmitted to the hospital within 30 days of discharge according to the Centers for Medicare and Medicaid Services (CMS). Most readmission happens within the first 16 days, making the case that proper transitional care and planning is essential for the patient’s recovery.

transitional home care caregiver

Planning….that’s what transitional care is truly all about. Yes, there are other factors involved but the core of transitioning from inpatient care to home, starts with a plan.
We all know the basic components of a well laid plan; answer the questions who, what, when, where, and how. But answering these questions can sometimes leave us scratching our heads. So, let’s go through each of these items together to help create clarity while you create your own transition plan:

WHO is going to provide care when your loved one transitions home? Is it you, part of your family, maybe even a hired caregiver? Or are you putting together a team of people to help you provide care? (hint, hint) This is not the time to claim superhero strength. No one person can provide 24/7 care for an individual who needs round-the-clock care. Be honest with yourself and call in reinforcements, whether they are hired or volunteers. You also don’t want to assume the individual can handle caring for themselves when they really cannot. Speak to the case manager at the hospital to help guide you in how much care is needed. My tip, more, in the beginning, is better! After a few days, you will have a better idea of how much care is needed. It’s better to be prepared than to assume…you know what they say about assuming.  😉

WHAT kind of care/equipment/supplies will be needed once they get home? Will they need Physical Therapy, maybe even Occupational Therapy? Will they need a walker or bedside commode? Will they need help walking, getting a bath, getting dressed, preparing food, etc. Based on the answers to your questions, you may need to seek Home Care assistance for both the medical and non-medical needs of the person. Again, your patient advocate or case manager should be able to help guide you.

WHEN should I start planning for the transition? The answer to this question seems to shock many people, but honestly, the answer is day 1. The first day of inpatient treatment is when you start thinking about and planning for the transition home. Obviously, you cannot lay concrete plans with dates attached until you know when discharge will occur, but this is the time to learn what options are available in your area. Reach out to the Case Manager or Patient Advocate to learn all you can about resources in your area. Ask friends who have been through a transition with their family members or friends. I cannot tell you how many families call me on their way home from rehab to see if we can provide a caregiver that day. Of course, we do our best to accommodate the situation, but a clear plan helps all parties involved understand expectations and goals for better outcomes for the patient.

HOW will the transition occur? Based on the individual’s insurance they may qualify for a rehab stay to create a smooth transition out of the hospital and build up strength to go home. However, there are times when the transition may be straight from hospital to home. In these instances, work with home care providers to aid in smooth transitions. Both Home Health (PT/OT, wound care, nurse visits, etc.) and Home Care (personal care, meal prep, laundry, light housekeeping, errands, etc.) can assist you in the transition process.

Whatever your needs may be in transitional care, remember, it all starts with a plan. We’ve put together a free transitional care checklist to help guide your thoughts and actions as you prepare a transitional care plan of your own. Click the link below to sign up for our email and receive this free guide!

We’d love to hear your thoughts and advice on transitional care! Comment below to share with our community or email us at What has helped you in creating a transitional care plan? What tips or tricks were valuable in the process? 

If you are located in or around Tallapoosa County, we would love to help with your transition plan! Call Beyond Home Care to schedule a free assessment today! 256.414.6090

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