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Care Transitions: Importance of Effectively Moving Care Settings

care transitions

A care transition is the process of moving a patient’s care from one setting to another. Improving care transitions enhances quality of life for the patient and reduces stress for the family and care providers. Examples of care transitions include a patient moving from the hospital to a skilled nursing facility or from the hospital to home with hospice care support.

The Importance of Improving Care Transitions

When a patient moves from one care setting to another, they often receive little information on what to expect in the new setting, next steps in their care, potential side effects in new medications, or information on when they can resume activities.

An effective care transition can:

  • Ensure the patient and their family have the information and support they need.
  • Prevent unnecessary hospitalizations and readmissions.
  • Prevent medical errors.
  • Avoid duplication of work and resources.

In short, a smooth care transition can make things easier at a difficult time, making it a more positive experience for the patient.

improving care transitions

How Crossroads Can Help with Care Transitions 

Hospital stays can be very difficult, particularly when a patient has a terminal diagnosis. Families must make important decisions about their loved one’s care while managing difficult emotions.

Crossroads Hospice & Palliative Care works with families and discharge planners to ensure the patient and family are prepared for a smooth care transition home. Our team can meet with the patient and family in the hospital to assess the patient and determine what support is needed to prepare for the patient’s arrival at home.

Medical equipment and medication related to the patient’s terminal diagnosed are fully covered by Crossroads. If the patient needs medical equipment like a hospital bed, the Crossroads team will arrange to have it delivered to the home. It will be set up for the patient and instruction on how to use the equipment will be provided to the family. Medications related to the patient’s terminal diagnosis will also be delivered to the home.

Once the patient arrives home, their care team will make visits throughout the week to supplement care provided by the family. Nurses and aides will visit to assist with the patient’s medical needs and personal care. Social workers support the patient’s psychosocial needs and can help coordinate care and connect the family to additional resources in the community. Chaplains and bereavement coordinators provide support for the patient and family’s emotional and spiritual needs. Hospice volunteers are also available to visit the patient to provide companionship and give family the opportunity to take a break to run errands, take a nap, or go for a walk.

By ensuring smooth care transitions from hospital to home, we make sure families can focus on spending quality time together.

To learn more about the hospice services we offer, please call 1-888-564-3405.


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Copyright © 2023 Crossroads Hospice. All rights reserved. 

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