Transitioning Care

Care Transitions and the Role of Home Care



Whether after a planned surgery or unforeseen stay, we can ease your loved one’s transition from the hospital or rehabilitation facility to home. This can lead to a safer and more comfortable recovery while preventing hospital readmissions and health complications.


Returning Home


Planning ahead and preparing for a safe return home can mean the difference between readmission and a full recovery. Many issues factor into why older adults are vulnerable to problems at home after they have been in a medical, hospice or rehabilitation setting. Some of the ways that Chosen Family can help with care transitions include:


Coordinating discharges: working with a patient’s hospital staff or care manager to help ensure discharge instructions and ensure that we can coordinate the patient’s needs to Chosen Family’s plan of care.
Medication management: helping the patient organize and track medications while ensuring that medications are taken as prescribed.
Follow-up appointments: keeping track of a patient’s necessary follow-up and routine medical appointments and ensures that the patient attends them.
Managing nutrition: assisting patients with food shopping and meal preparation to ensure proper nutrition, diet, and hydration that facilitate the patient’s recovery.
Monitoring risks: watching for warning signs and taking appropriate action and notifications to mitigate risks.
Record keeping: Taking note and keeping track of the patient’s recovery to be shared with the patient’s doctors or care team.


Personalized and Tailored Care Transitions


Each individual’s discharge and transition from one care setting to another is unique. Chosen Family recognizes that this post-discharge period is critical and can make the difference between a strong recovery and unwanted health complications or a hospital readmission.


Chosen Family offers a variety of transitional care services that are tailored and personalized to the individual. We help coordinate communication and care across health systems involved to give the patient the greatest chance at a happy and successful recovery. Contact Chosen Family today to learn more about how we can help.