The term “transitional care” refers to a range of services designed to promote the safe and timely continuity of care for patients as they move between care settings. High-quality transitional care is especially critical for older adults with multiple chronic conditions and complex, multi-specialty care plans, who require continuity of care as they move frequently between care settings.
The National Institutes of Health reports that suboptimal “handoffs” of these older adults and their caregivers from hospital to home have been linked to adverse events, low satisfaction, and high rehospitalization rates. Transition Care Management (TCM) improves patients’ quality of life and helps reduce hospital readmissions.
Providers who round at a hospitals, skilled nursing facilities & rehab hospitals with especially vulnerable geriatrics patients and their family members need assistance in discharge planning, transitional care, and in home care to ensure the success of patients who have returned to their home environment.