Transition care—changing a downhill slope to a recovery triumph

As your loved ones transition from hospital or nursing home care to home, you may have seen a concerning pattern where they get readmitted within months. This could be due to unmanaged medication, missed doctor appointments, and the lack of care for chronic illnesses. With at least one in five people with Medicare getting readmitted within a month of discharge, it is time to explore alternatives. Preferred Care at Home’s innovative Smooth-Transition Care program offers a solution that empowers patients with a personal coach, Personal Health Record, and online health record.

At Preferred Care at Home, we don’t just talk about it. We make it happen with our innovative Smooth-Transition Care program.”

What Is Smooth-Transition Care^®?

A hospital or nursing home discharge can leave a patient feeling overwhelmed and uncertain about their recovery. With rehabilitation instructions, prescriptions to fill, and follow-up appointments to schedule, there’s a lot to keep track of. After returning home, building up strength is only part of the challenge; it can be difficult to remember all the tasks that need to be completed, especially for elderly individuals who often live alone.

At Preferred Care at Home, we’ve developed the Smooth-Transition Care® program to address these issues and help patients feel at ease during the recovery process. Our program provides a personal, specially trained coach who will guide patients through the transition process, making sure they have what they need to recover safely and comfortably. With a 15-piece tool kit called the Personal Health Record, we help patients stay organized and informed about their medication instructions, appointments, and test results. And with an easily accessible online health record, patients can share up-to-date information with health care providers and family members who need it.

As a Smooth-Transition Care^® client, you’ll receive three tools to help you stay out of the hospital:

1.  A personal, specially trained coach.

Your coach will meet you at the hospital, nursing home or other health facility and guide you through the transition process. After your discharge, your coach will meet with you regularly, through phone calls or visits, and make sure you have what you need. For example, your coach may schedule transportation to follow-up appointments, remind you about prescriptions and medication regimens, and make sure your home is safe. Your coach will also provide a listening ear and encouraging words.

2.  A Personal Health Record.

This in-depth, 15-piece tool kit stores the information you need to transition optimally, including medication instructions, appointment dates and test results. Your coach will encourage you to use this tool. The record also includes an easy-to-read symptoms chart that shows when you can wait and see your doctor and when you should call 911. You can view the Personal Health Record and even download the pages for free.

3.  An easily accessible online health record.

No need to tote the Personal Health Record with you to every doctor appointment. As a Smooth-Transition Care^® client, you’ll have exclusive access to your own online health record. Upon your request, your coach will add this information to your secure, password-protected database. You can share it with health care providers and family members who need up-to-date information.