Recovering from a hospital stay can be overwhelming. You might be managing a chronic condition, healing from surgery, or adjusting to a new healthcare routine. Whatever the reason for your stay, the transition from hospital to home can be challenging and complex. Transition of care programs help patients recover smoothly and safely by providing support and services that lower the chance of going back to the hospital.
Could you benefit from transitional care? Learn more about how transitional care programs help patients regain strength and confidence as they move from hospital care back to daily life.
What is a Transition of Care Program?
Transitional care (also called transition of care) prepares patients to return home after a hospital stay. During the transition, healthcare providers help patients manage medications and maintain their rehabilitation therapy schedules.
A study published by the National Library of Medicine looked at the impact of two types of transitional care programs — nurse/social-worker-led post-discharge phone and interdisciplinary case-coordination transitional care programs).
Both types of programs proved to have a positive effect on patients:
- Readmissions were reduced by 5%
- Emergency department visits were reduced by 13%
- Follow-up care adherence improved by 75%
These figures illustrate how transition of care programs improve patient outcomes. But how can you determine whether you (or a loved one) need transitional care?
5 Signs That You Could Benefit from Transitional Care
1. You Were Recently Hospitalized
A hospital stay can take a toll on your body and mind, and returning home can feel overwhelming. Many patients need help with:
- Managing medications and treatment plans
- Monitoring potential complications
- Following up with providers
Transitional care services ensure that you have the resources and support you need to recover safely, reducing the likelihood of being readmitted to the hospital.
2. You Have a Chronic Condition that Requires Ongoing Care
Chronic health conditions like heart disease, diabetes, or COPD require consistent care and monitoring. A hospital stay can disrupt your regular treatment routine, making follow-up care even more critical to avoid worsening symptoms.
Transitional care can help you establish a new routine for managing your condition and medication schedule. You’ll have a plan to help keep your health on track.
3. You Need Rehabilitation After a Hospital Stay
For many patients, hospital discharge doesn’t mean they are 100% recovered. They need additional therapy or rehabilitation services before they are ready to regain their independence. For example, physical therapy, occupational therapy, or skilled nursing support for wound care may need to be provided.
Transitional care teams work with patients to develop and maintain a rehab plan so they have the support and structure needed to heal.
4. You Have Difficulty Managing Follow-Up Care
It’s easy to forget new medications or miss a follow-up appointment, but doing so can cause you to be readmitted to the hospital. Managing medications, scheduling doctor visits, and following recovery plans can be tricky to manage on your own, especially if you have complex medical needs.
Transition of care helps by organizing medication schedules, coordinating follow-up appointments, and connecting you to home health services. Essentially, you won’t have to navigate recovery alone.
5. You or Your Family Feel Overwhelmed with Recovery
The road to recovery can be stressful, and not just for patients. Caregivers and family members can feel the strain as well. If you or your loved ones are unsure or unprepared to manage care at home, transitional care can bring peace of mind.
The transition care team can educate you or your loved ones about your condition and care plan and help coordinate a well-managed recovery process. Transitional care teams can also offer caregivers support and help them feel more confident about assisting with recovery.
Safer, Easier, and More Successful Recovery Care
If you or a loved one are experiencing any of these signs, consider transition of care support. It could help you safely heal and avoid hospital readmission. EARH’s transitional care program provides personalized, expert care to guide you through this time and help you return to your daily routine.
Don’t navigate recovery alone. Learn more about our Transitional Care unit and how we can help support you or a loved one after a hospital stay.
