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What is Transitional Care?

Transitional Care is the coordination between different care facilities to provide a better continuum of care. Healthcare settings include:

  • Hospital and Medical Center
  • Primary care center, place of surgical care
  • Secondary Care Location when Discharged
  • Skilled Nursing Facility (SNF)
  • Convalescent / Nursing Home
  • Assisted Living Facility
  • Personal Home / Residence
  • Home Health Agency (HHA)
  • Visiting Nurses. RNs and LVNs, perform certain tasks in your home;
  • Health Checks
  • Wound Care
  • Physical Therapy
  • Arranged by medical center to assist in patient’s recovery
  • Home Care Organization (HCO)
  • Personal care services at home using:
  • Caregivers
  • Nurse Aides
  • Home Health Aides
  • Personal Care Assistants

Transitional care recognizes your care needs change over the course of recovering from an acute or chronic condition and strive to follow a Care Plan that best suits your needs.

The main goal is to provide the best care that you need to fully recover and maintain your health instead of being readmitted to a medical center.

Transitional In-Home Care Reduces Hospital Readmissions
There have been many changes in the health care industry in the last few years. The main
difference is shifting focus from care provided within a strictly medical environment, such as a hospital, convalescent / nursing home or skilled nursing facility. People recover better in the comfort or their own homes but it’s important they have the professional care and assistance needed so they don’t need to be readmitted to a hospital. Transitional Care from Hospital to Home.

Studies by Centers of Medicare and Medicaid Services (CMS Hospital Readmission) show about 30% of elderly or senior patients are readmitted to a hospital within 30 days of being discharged home.

This is due to the focus of care being on the patient “in the moment” instead of a long-term care plan. It’s been proven that looking at a “Patient’s health and progress as a whole” lowers the chances of a patient relapsing and having to return for another hospital stay. Having professional, experienced home care services helps your loved one transition from a medical facility to a loving home environment successfully. Our Transitional Care Services at A-1 Home Care Agency helps with all essential, non-medical issues you need for a speedy and complete recovery, at home. To recover from illness or surgery, it’s important that you maintain personal hygiene, eat nutritious meals – not convenient fast food or TV dinners, live in a clean environment, sleep in sanitary bed linens, attend follow up doctor’s appointments and take prescribed medication as schedule. We work with your Medical Healthcare Team and follow your Care Plan, providing what your body needs to recover and a shoulder to lean on so you can rest and concentrate on healing. We are trusted by many reputable medical centers and health facilities for our excellent and affordable elderly and senior care, after surgery care and post-stroke recovery assistance.
These include:



Call A-1 Home Care today to arrange Transitional Care for a loved one.

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