For most patients and their families, an unexpected stay in the hospital can a disorienting and possibly life-changing event.  In addition to health concerns that brought them to the hospital in the first place, patients are often bombarded with a huge amount of complex information, within a short period of time. From new diagnoses and medications to arranging follow-up appointments, procuring the necessary equipment, and adjusting to sudden lifestyle changes, the immediate days after discharge are crucial. Even though hospitals do everything they can to make sure that their patients are discharged with a plan for their continued care, patients and their families often find it extremely challenging to understand and adhere to new routines and requirements – especially if their PCP is left out of the loop and there is no follow-up or guidance during the transition period. When searching for transitional care management (TCM), understanding the specific needs of your loved ones can make the difference between full recovery and unnecessary setbacks.

What is Transitional Care Management?

Transitional Care Management addresses the hand-off period between the inpatient and community settings. After a hospitalization or other inpatient facility stay, the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Approximately one in five Medicare beneficiaries in the United States are readmitted to the hospital within 30 days of discharge and up to 76 percent of these readmissions may be preventable. A common reason for readmissions is the absence of timely follow-up appointments with primary care providers to assist patients with their new diagnoses, medications, and treatments. Dementia, heart disease, COPD, diabetes, and other chronic conditions can often be managed in the patient’s community setting. When there is an interruption in care while the patient is being transitioned from inpatient to in-home care, however, it can put the patient at risk for relapse and increases the risk for readmission. Transitional care management exists to ensure continuity of care during this transition period.

Questions When Searching for Transitional Care Management

There are a number of things to consider prior to agreeing to transitional care for your loved one. The average length of stay for individuals in transitional care is 8 to 20 days. With this knowledge, you’ll want to ensure the community or care program you and your loved one chooses has the amenities and specific clinical requirements needed for a full, safe process of regaining health and independence.

When meeting with a community, be prepared with a list of questions and concerns you may have. Keep in mind each individual is different, and the specifics required by you and your family should be properly addressed by the transitional care staff, including:

  • Medication Management – including prescribed medications plus pain medication as directed by providers post-surgery
  • Nutrition – can your loved one choose from a variety of meal options?
  • Mobility – what are the options for recovery if mobility has been temporarily compromised due to illness or injury?
  • Therapy – including physical, occupational, speech, and recreational
  • Social interaction – does transitional care offer the socialization and inclusion in community events should your loved one so desire?

When your loved one is faced with an illness or surgery, it can be overwhelming to consider the road to recovery, especially if you or other family members live far away. Trying to establish the care plan, coordinating transportation for follow-up medical visits, and ensuring all medication and post-treatment plans are followed closely can be a major undertaking. Transitional care management is an important piece of the puzzle for monitoring and managing chronic conditions. As more and more seniors want to continue living independently for as long as possible, TCM helps ensure that the patient’s needs are being met.

Here is How Discover Health Advocacy Helps

As your advocate, Discover Health provides the research about patient diagnoses and medications so patients can understand their medical care and make educated decisions about their treatment.

From beginning to end, we’re on the side of the patient. Our goal is to empower the patient by ensuring their wants, needs, and wishes are met by their healthcare providers. We speak the language of patients, doctors, and caregivers, which helps us translate the complex messaging that comes with navigating the world of healthcare.

Our focus is working for you. Not a healthcare system or insurance company, just you. By developing important questions and gathering the right information, Discover Health Advocacy helps you get the most out of your doctors visits. There’s never a reason to feel alone or scared when hospitalized or with a physician because we assure you’re always in good hands.

Discover Health provides advocacy services to support caregivers and their loved ones with personalized strategies to manage complex care. Find out more by calling us today.

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