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How Seamless Transitions Can Reduce Hospitalizations

September 10, 2019 | Blog

A seamless transition of care from the hospital is essential to reducing re-hospitalization in the future. The most critical time period is in the first 72 hours. Whether the transition is for respite care, to a post acute care setting, back home or to an assisted living or memory care community, it can be crucial to a patient’s health to have a successful outcome. An individual can be in transition and receiving care and services for many reasons. It can be because he/she is retiring, just had surgery or was diagnosed with a severe illness. For these reasons, being home alone has become hazardous and could lead to further complications. Transitioning to the right healthcare agencies that can provide the right services to meet your needs is very important and could help determine the outcome of patients’ overall health. Therefore, strategically planning a seamless transition of care for you or a loved one is a must.

It is never easy transitioning your elderly parents or loved ones to a new setting, which is why it is paramount to ensure they have a smooth transition of care. Transitional care is composed of safe and timely transfers between different levels of care. This is extremely important for individuals with chronic diseases or illness considering that they are more susceptible to injury or further complications. So how do you create a smooth transition of care?

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Determine Moderate or High-Risk Patients:

Caregivers play such a critical role in ensuring a smooth transition of care because they take on the responsibility of providing the patients’ current medications, allergies or other health issues as well as planning their next site of care. They also help determine whether a patient is low, moderate, or high risk of readmission. This can help in understanding what specific services should be provided in order to ensure enhanced support and reduced readmission. With this in mind, it is important for healthcare professionals to understand whether a patient’s risk factor to reduce readmissions from a poor transition of care.

Prevent Incomplete Discharge:

Proper discharge from any setting is paramount in confirming a smooth transition of care. An incomplete discharge can be detrimental to patients’ health. As explained in an NCBI publication, “nearly 30% of older people experience some delay in their hospital discharge, which is known to expose patients to additional hospital-related risks, create emotional and physical dependency, incur additional hospital costs.“ The Continuity Assessment Records and Evaluation tool created by the CMS can assist throughout your transition of care. This tool not only provides up-to-date information of discharge but also includes, a standardized assessment of the patient’s medical, functional, cognitive, and social conditions throughout environments of care. Ask your healthcare professional if this tool is available at your hospital or nursing home.

Get Support:

The process of moving between different healthcare settings can be overwhelming and scary to some people. Nonetheless, there are transition coaches, programs and services that can aid you along your journey. These transition coaches are advanced nurses that educate both the patient and caregiver on specific skills needed to promote a smooth transition of care. Studies have shown that “hospital costs were approximately $500 less” and “had lower all-cause re-hospitalization rates through 90 days after discharge,” for patients with transition coaches. Ask your healthcare professional if this service is available at your hospital or nursing home. Transitional care programs are also available through some home care agencies and have been known to reduce re-hospitalization by less than 3%. Many assisted living and memory care communities have special associates designated to focus on the transition with special programs to welcome new residents.


At Spring Hills Senior Communities, we follow all necessary safety precautions to ensure that there is a smooth transition of care to and from our facilities. One of our Signature Touch programs is our WOW moments. WOW at our company stands for Willingness to Observe our Residents’ Wishes. We get to know our residents prior to their move-in by speaking to the family members and having pre-care conferences designed to get to know everything about their life before needing our care. From there, we come up with a gift that will truly WOW them. Our goal is to ease the recovery process and prevent hospital readmission by ensuring a smooth transition of care to and from our facilities.

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