Transitional Care for Seniors

Transitional care for seniors in Arizona is something that 9,000 families a day are confronted with. Whether transitioning home from a hospital, nursing home, skilled nursing facility, or rehab that transition period is critical in a senior’s recovery. Make no mistake transitional care is vital and something you must be ready to deal with.

Let me paint a picture of transitional care. In many cases, your loved one is frustrated and wants to come home. They have spent weeks at a facility working to gain strength so they will be free to come home and live safely. You have spoken to a multitude of people. Physical therapists, occupational therapists, doctors, nurses, CNA’s, and care managers. All are offering their input, suggestions, and the next steps. It is overwhelming for any family!

Transitional Care for Seniors

Prior to a senior’s release, you will have spoken with a case manager, care manager, or discharge manager. They have stated they will be sending home a “care plan.” These are the next steps in the care process, and they are important. Now, is it a simple plan? No in many cases, they are transporting your loved one in a wheelchair and have several hundred pages in tow. That is the care plan! Mixed in all those documents are the next steps, plans, dos and “don’ts” and everything in-between.

Transitional Care for Seniors. Here are a Few Items and Questions Contained.

How do you navigate all of that? Do you need to be scheduling appointments?

Who is coming to the home?

How does all this information get shared with your primary care physician and specialists?

New medications?

How do they work with your other medications?

What are the benchmarks in your recovery plan?

How is monitoring my progression?

Will there be any dietary restrictions?

What will insurance cover?

Does Medicare cover anything?

Can my family help me in recovery?

Is there More?

These are just a few of the questions and concerns that many families face as they transition home. Bear in mind your thoughts have little to do with these matters. You are most worried about how you feel. Can you do the day-to-day things? Getting back to “normal” living is the top priority. As it should be! Transitioning home from any of the facilities we have mentioned, you are tired, frustrated, and just want to be in your own bed, eating your own food, and being around the people you love!


So how do you Best Manage Transitional Care?

This is a question we receive daily, literally a daily basis. First, if you are not seeking the help of a professional, IE. an In-Home Senior Care company like ours, you can take the following steps.

  • Designate one person in your house that communicates with the discharge or care manager at the facility. One voice, that will communicate from beginning to end. To many people, having too many versions of the situation often makes it more confusing.
  • Call the primary care physician right away. Inform him or her of what has happened, and what will be happening, and you want to set an appointment to review the care plan with them.
  • With the step above, now do this same task with all your specialist’s doctors as well.
  • DO NOT call a medical supply company. If you need a hospital bed, Hoyer lift, walker, or scooter get this referral from the facility of home care agencies. Have a professional negotiate or source this equipment for you. It will save you $1000s of dollars, plus they will ensure it is in the home on time!
  • Designate one person in the family that ensures physical activity, make this the “strong” person in your family. Often when transitioning home, the senior wants to rest and ease back into the process. This is NOT a time for stagnation. Movement in continual health improvement is critical. Put together a guide of range of motion exercises!
  • DO NOT rely on physical therapy ONLY. PT is there once or twice a week. That is not the only plan. Have a range of motion exercise plan made in advance and at the ready.
  • Once you know the dietary restrictions, designate a family member to now pre-make all of the meals, with those restrictions strictly enforced. Do not leave it to the seniors to do this for themselves. Have a minimum of 1 week of meals made and labeled.
Transitional Care by professionals.

Working with a dedicated home care agency can make all of the difference in the world when transitioning.  Look at just a select number of the advantages.

  • Our in-home care manager works directly with the hospital, skilled nursing facility, or rehab. That way, we can understand their post stay plan and integrate it into our custom care plan. NO wading through red tape, we handle it all.
  • Each of our caregivers is certified in specialty areas. Stroke, dementia, Alzheimer’s, Parkinson’s, Personal Care, Respite, Live In, Range of Motion, Deaf, and more. In short, you will have a caregiver dedicated to you or your loved one to ensure transitional recovery.
  • Meal prep is crucial. Each of our caregivers will follow our published recipe books. Knowing how to carefully cook, adhere to restrictions, and maintain the taste and quality is an area we excel!
  • Coordinating with all doctors and specialists. From your PCP to specialists we will set appointments, provide transportation, and medicine logs, and coordinate amongst all offices.
  • Work hand in hand in physical or occupational therapy. By continuing your strength and dexterity through our range of motion exercises. We make those custom to your unique situation.

This is a very small list of what a dedicated agency can do for you! There are 1000s of moving parts in transitional care for seniors, just know you are not alone!

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