Transitional Care

Many factors contribute to gaps in care during critical transitions. Poor communication, incomplete transfer of information, inadequate education of older adults and their family caregivers, limited access to essential services, and the absence of a single point person to ensure continuity of care all contribute.

At Glory Hospice & Palliative Care, our Transitional Care Program focuses on our highly vulnerable, chronically ill patients throughout the critical transition phase during a movement from one healthcare setting to either another or to home. Our emphasis is on educating patients and family caregivers to address root causes of poor outcomes and to avoid preventable rehospitalizations.

Transitional Care refers to the coordination and continuity of health care which encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers. These patients typically receive care from many providers and move frequently within health care settings.

Family caregivers play a major—and perhaps the most important—role in supporting older adults during hospitalization and especially after discharge. Until recently, however, little attention was paid to family caregivers’ distinctive needs during transitions in care. Consequently, family caregivers consistently rate their level of engagement in decision making about discharge plans and the quality of their preparation for the next stage of care as poor.

Caregiving can be rewarding, but it can also impose burdens on family caregivers. The stress of caregiving is likely to be exacerbated during episodes of acute illness. Glory Hospice & Palliative Care attends to the emotional needs of caregivers during transitional care to help minimize their negative experiences and to enhance their ability to support their loved ones.

Our Transitional Care Program is an additional service provided by Glory Hospice & Palliative Care. It is not a payable level of care under the Medicare hospice benefit. It is designed to ensure the coordination and continuity of our patients as they transfer from one health care setting to another or home. We will stay up to 8 hours after discharge in order to assist the caregiver and meet the needs of our patients. Our RN will complete an assessment to determine the length of time the CNA will remain in the home or health care setting, coordinate DME and medication management. Our RN will make a re-visit to reassess the patient and/or caregivers needs.