Transitional Care

One of the most critical times for extra support is when your loved one is being discharged from a hospital or rehab stay after an injury or illness. When a person comes home after an injury or an illness, they are much more likely to reinjure themselves or be hospitalized in the weeks immediately following their discharge. This is a key time to bring in Beyond Home Care to help not only provide your loved one with care while they recover, but to help coordinate and facilitate all the moving parts that come with transitioning back into the home. 

We have developed a 3 stage Transition Plan to support this process before, during, and after the transition. This approach works best when the family or case manager contacts us at the beginning of a person’s hospital or rehab stay, instead of waiting until discharge to make a plan, but we are always ready to step in when called upon.


Beyond Home Care’s “There’s no place like home” Transition Plan includes:

  • Safety Checklist for the home including fall prevention 
  • Coordinating discharge with the hospital or rehab facility
  • Coordinating services and care plan with Home Health including PT/OT
  • Training and documenting all PT/OT exercise routines and following for compliance
  • Communicating discharge orders and medications with your primary care physician
  • Helping schedule and coordinate follow-up appointments 

Let's Talk

Request a call to discuss how we can provide you with personalized care.

Or Call: 256.414.6090

More Resources on Transitional Care