Transitional Care

TRANSITIONAL IN HOME CARE

What is Transitional Care?

Transitional Care is the coordination between different care facilities to provide a better continuum of care after a medical procedure or hospitalization.

Your recovery is handled in states:

Hospitalization
Transfer to convalescent or rehab center
Discharge Home

If you are recovering well, you may be allowed to go home instead of being transferred to a convalescent / nursing home, assisted living facility or rehab center.

Transitional care is the term used as you move from one care setting to another and eventually home.

Healthcare settings and recovery support provided may include:

Hospital and Medical Center

Primary care center, place of surgical care

Secondary Care Location when Discharged from Medical Center

Skilled Nursing Facility (SNF)
Convalescent / Nursing Home
Assisted Living Facility

Discharge to Personal Home / Residence

Arranged by medical center to assist in patient’s recovery

Home Health Agency (HHA)

Visiting Nurses. RNs and LVNs, perform certain tasks in your home
Health Checks / Follow Up Visits
Wound Care
Physical Therapy

Information Provided by Discharge Planner / Social Services

Home Care Organization (HCO)

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 healthcare 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 of their own homes but it’s important they have the professional care and assistance needed so they don’t have to be readmitted to a hospital.

Studies by Centers of Medicare and Medicaid Services (CMS Hospital Readmission) show that 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 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
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.

How A-1 Home Care Agency Can Help

We offer Value Plan Pricing for:

Discharge Services
- Transportation from medical center to home
- Pick up prescription
- After Surgery Care by experienced caregiver
- Post-Op Care and Assistance for required 24-hour period
Transitional Care:
- Assistance from medical center to home
- Pick up prescription
- After Surgery Care by experienced caregiver
- Ongoing Assistance for duration of recovery

Our Home Care Services Include:

Assistance with Activities of Daily Living (ADLs)
- Bathing, Dressing and Grooming Assistance
- Incontinence Care / Toiletry Assistance
Safety Supervision
Medication Reminders
Mobility Assistance / Transferring
Range of Motion Exercises
At Home Care Includes the Above and:
- Meal Planning and Preparation
- Light Housecleaning and Laundry
Companionship

Advanced Services Provided:

After Surgery / Post-Acute Care
After Stroke Recovery Care
Heart Attack / Bypass Surgery
Traumatic Brain Injury TBI
Cancer and Chemotherapy Care
Diabetic Care
Dialysis and Kidney Disease Care
Dementia and Memory Care
Parkinson’s Disease
Alzheimer’s Disease
Arthritis / Pain Management
ALS / Lou Gehrig’s Disease
COPD
Disabled, Handicapped and Developmentally Delayed
- Manic Depressive Disorder
- Cystic Fibrosis
- Muscular Dystrophy
- Multiple Sclerosis
Low Vision / Blindness
Hearing Impaired / Deaf
Hospice, Palliative and End of Life Caregivers

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:

We have caregivers that are experienced with helping people recovering from:

Appendectomy
Brain Injury
Cancer and Tumor Care
- Biopsy
- Chemotherapy and Radiation Treatment
- Mastectomy
Cardiovascular
- Bypass Surgery
- Coronary Artery Bypass Surgery (CABS)
- Stent Placement
- Valve Replacement
Gallbladder Removal
Gastrointestinal Surgery
- Colectomy – Partial Removal of the Colon
- Colonoscopy
- Gastric Bypass Surgery
- Esophageal Surgery
Hernia Repair Surgery
Hip / Knee / Joint Replacement
Hysterectomy
Optical Surgery
- Cataract Removal
- Glaucoma Surgery
Organ Transplant Surgery