Transition Care
Transition care is the support and coordination provided to patients transiting from one healthcare set up to another, ensuring a safe and smooth recovery, this may be an interim shift from a hospital to home. The objective is for the patients to regain independence and confidence by providing services like medication management, rehabilitation, and help with daily activities. This is coordinated by a dedicated care team. The goal is to ensure a smooth transition, prevent complications, and support a return to normal life.
What transition care involves
⇒Discharge planning: A comprehensive plan is made to help patients transition from the hospital to their next setting.
⇒Medication management: A review of new and existing medications, including refill coordination and patient education.
⇒Rehabilitation and therapy: Services like physical or occupational therapy to restore muscle strength and functional independence.
⇒Continuity of care: A single point of contact, like a transition coach or nurse, helps coordinate care, communicate with other providers, and follow up with the patient at home.
⇒Education: Providing the patient and their family with the knowledge and tools to manage their health at home.
Where it can be provided
⇒At home: In-home visits and support are common components.
⇒At an aged care home or rehabilitation facility: Patients can stay in short-term, specialized centers designed for recovery.
⇒In the community: Some services can be delivered in a mix of locations.
Why it is important
⇒Aids recovery: It provides structured support that helps patients recover faster and more fully than with just rest at home.
⇒Improves functional independence: It helps patients regain confidence and the ability to perform daily tasks independently.
⇒Ensures safety: It helps prevent complications that can arise from abrupt changes in care or information gaps.
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