Care Transitions

Care Transitions

When it comes to long-term care, people often use more than one solution over time. As people switch from one type of care to another, there is a transition period.

The American Society on Aging describes care transitions as, “…the movement of patients between one care setting or care provider and another.” The American Geriatrics Society has defined a care transition this way: “…a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.”

A care transition may occur when someone leaves the hospital and needs support to heal at home after they’ve been discharged from the hospital, or it might happen when someone who is receiving in-home care decides to move into a supportive community, such as assisted living or senior housing. The goal is to avoid a gap in care for the individual as they pivot from care type.

Moving On

When someone leaves the hospital or a rehab facility for home, their doctor or nurse can’t go with them and a family or professional caregiver might be needed as they continue to heal at home. For example, someone might need help with using the bathroom, taking new medications, or going back to see the doctor for follow-up appointments.

An even longer and different type of transition may occur when someone decides to move from their current residence to a new one—whether that is from a stand-alone home into a senior housing apartment, assisted living facility, or in with family across town or another state. A caregiver can be of help in this type of transition also.

Make New Friends

A caregiver—whether a family member or a professionally-trained one—can help to make the transition smooth. When someone is choosing to move to a new setting, they may be waitlisted or have many weeks or even months of time spent preparing to sell a property or end a lease. During this time, with assistance, they can begin to get comfortable in their future home.

If they are transitioning to an assisted living facility, inquire about opportunities to join in meals and activities prior to moving in. This type of engagement can help the individual feel more relaxed about their new surroundings and making a big change. They will also have an opportunity to learn more about policies, procedures, and costs that come along with their new environment. In many settings, it is an option to maintain a caregiver to help with daily activities in senior housing or assisted living, so it can be helpful to the caregiver to also learn as much as possible about this new place.

When making changes in long-term care options, aim for a continuity of care during the transition so risks for setbacks are minimized and chances for success are increased.

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