Transition Care: Do You Understand Your New Care Plan?

For many seniors, transitions from hospital stays to rehab facilities to home or assisted living facilities can be an overwhelming and confusing ordeal. There are new doctors’ orders and prescriptions, and instructions for physical therapy, occupational therapy and follow-up visits. All this often brings more questions than answers.

Have you experienced something like this? In fact, it’s during these times of transition that you’re the most vulnerable to readmission due to falls, medication errors and a lack of understanding about the new regimen. Our Smooth-Transition Care program can assist you during this transition, helping you and your family understand the new care plan. Our goal is to reduce readmission rates across the nation. That starts with personalized care for every client.

Our Smooth-Transition Care program provides a transition coach to help with the development and follow-through of a care plan. One thing the coach will do is help you complete a Personal Health Record. This record provides the information you need to understand and organize your total health-care plan. But the role of our Smooth-Transition coaches doesn’t stop there. Not only will they help with the Personal Health Record, but they’ll encourage you to be an active participant in your own care.

According to the Department of Health and Human Services, over 55 percent of seniors discharged do not follow the medication regimen their doctor recommends.  Often, this is because seniors don’t understand their new regimen or forget to take their medication at the proper times. One way a Smooth-Transition coach confronts this problem is by coaching you on questions to ask you doctor and providing tools for you to become an active participant in your care.

Are you in the midst of a transition? Contact a Smooth-Transition coach today for information and tools to help make it a smooth one.