Transition Care

Home Services Transition Care

Hospital-to-Home Transition Care

Transition care—changing a downhill slope to a recovery triumph

You’ve probably seen it with loved ones. An elderly person checks out of a hospital or nursing home only to be readmitted within a few months. During the transition, medications weren’t taken, doctor appointments weren’t made and chronic illnesses weren’t cared for. The downward spiral seems unstoppable, the medical bills never-ending. And you’re at a loss for what to do.

At least one in five people with Medicare are readmitted to the hospital within one month of discharge.

But what if hospital care were different? Instead of sending elderly people home alone with confusing instructions and to-do lists, what if we also sent a coach—a trained expert to guide, encourage and empower? What if that transition care service were affordable?

At Preferred Care at Home, this isn’t a pipe dream. We’re making it a reality through our innovative Smooth-Transition Care program.

Download our hospital-to-home brochure written specifically for you

What Is Smooth-Transition Care®?

A transition from a hospital or nursing home can be confusing. You get rehabilitation instructions, prescriptions to fill, follow-up appointments to make. When you get home, you don’t just have to build up your strength, but you’re supposed to remember all these other things—and have the energy to do them. For elderly people, recovery can be even more overwhelming because they’re often alone.

With our Smooth-Transition Care® program, we’ve addressed each of these problems and developed a solution that helps put patients at ease so they can focus on getting better.

As a Smooth-Transition Care® client, you’ll receive three tools to help you stay out of the hospital:

1.  A personal, specially trained coach

Your coach will meet you at the hospital, nursing home or other health facility and guide you through the transition process. After your discharge, your coach will meet with you regularly, through phone calls or visits, and make sure you have what you need. For example, your coach may schedule transportation to follow-up appointments, remind you about prescriptions and medication regimens, and make sure your home is safe. Your coach will also provide a listening ear and encouraging words.

2.  A Personal Health Record.

This in-depth, 15-piece tool kit stores the information you need to transition optimally, including medication instructions, appointment dates and test results. Your coach will encourage you to use this tool. The record also includes an easy-to-read symptoms chart that shows when you can wait and see your doctor and when you should call 911. You can view the Personal Health Record and even download the pages for free.

3.  An easily accessible online health record.

No need to tote the Personal Health Record with you to every doctor appointment. As a Smooth-Transition Care® client, you’ll have exclusive access to your own online health record. Upon your request, your coach will add this information to your secure, password-protected database. You can share it with health care providers and family members who need up-to-date information.

Health care providers: Click the picture to download our hospital-to-home brochure written specifically for you.

At Preferred Care at Home, we’re committed to finding the best solutions that help elderly people transition to their own home safely. We work to make services like our hospital-to-home transition care affordable for everyone. To learn more about Smooth-Transition Care® and find the cost in your area, please contact us today to experience the Preferred Care at Home difference.

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