Transitional Care

A Safe, Smooth Transition from Hospital to Home 

After a stressful stay at the hospital or rehabilitation center, we understand the importance of your loved one getting back into their home.  Leading Edge Senior Care can assist with our professional support to make the transition back home easier. Having transitional support is proven to lower the chance of a hospital readmission and improve your loved one’s recovery time. 
Transitioning back home can be a confusing time with rehabilitation instructions, prescriptions to fill, follow-up appointments to make; this can become very overwhelming for you and your loved one.  Your loved one needs to focus on getting stronger, not being overwhelmed by all of the changes in their care.  Below outlines how our transition support team will enhance your loved one’s recovery: 
  • Personal Transition Coordinator 
Your transition coordinator will meet on your behalf with the hospital’s Discharge Planner prior to your release. They are able to work collaboratively with the discharge planner to establish a plan of care that addresses your key recovery needs as well as coordinate additional services, medication regimes, equipment or even do a home safety check of the environment.  Your Transition Coordinator will complete a discharge checklist to ensure your loved one has everything he/she needs once home.  Once your loved one is home, the transition coordinator will complete weekly visits and phone calls to ensure your loved one is on a positive path to recovery. 
  • Our Transition Team is Always There When You Need Us  
Your Transitional Coordinator will introduce the Personal Care Assistant who will assist with your recovery plan. Your Personal Care Assistant will address areas that improve your daily functioning such as therapeutic exercises (if ordered by the physician), meal preparation for good nutrition, hydration, skin care, bathing & hygiene assistance (if needed), mobility techniques to make moving easier, and medication reminders.  In addition, your Personal Care Assistant can complete all of your errands, schedule appointments, escort you to appointments, laundry and housekeeping. Your Personal Care Assistant is trained to notice red flags and how to respond if an emergency should occur. 
  • Our Family Portal 
You will be able to stay up to date with your loved one’s care simply by visiting our secure, online family portal.  You will be able to read the care notes from the Personal Care Assistant’s visits and the Transitional Coordinator’s visits.  Of course, we are always a phone call away also.                                                                                           
Typically our transitional team is involved for 30 days after discharge, while it is possible you will not need care beyond the 30 days; we are here to assist you with our in-home services if you need additional assistance. Prior to the 30 days, your Transition Coordinator will communicate with you and your loved one to establish if further private home care is required on an ongoing basis and to develop a specific care plan for ongoing services. 
Make a Smooth Transition Home, Contact Us Today (480) 618-5995 


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