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Our Guide to Care Transitions for Your Senior Relative

Taking care of senior relatives can be more complicated than expected. Following the instructions of discharge papers is incredibly essential for after-care treatment to ensure optimal comfort for your senior relative. These papers contain information that spells the difference between recovering comfortably at home or returning to the hospital.

This process, known as care transition, needs a comprehensive program to ensure that patients fully recover and no longer need to return to the hospital for preventable issues. This especially applies to seniors, as they can feel fatigued or overwhelmed once they’re discharged, and may feel too disoriented to fully comprehend after-care instructions. They might even speed through the discharge process just to get home faster.

Why Care Transition is Important

A solid care transition program is crucial to keeping your senior relatives in top shape throughout their recovery period. Otherwise, a poorly executed transition that can be costly, especially if it leads to problems that could have been avoided. Your senior relative may have to make longer, more frequent trips to the hospital, incurring expenses in the emergency room, ambulatory services, and others.

Sticking to a care transition plan eradicates these programs and ensures that your senior relative receives the best treatment possible. It will reduce the chances of contracting complications, which can be fatal for senior patients.

Knowing the Different Providers

There are different providers of care transition programs that can help address common issues encountered by senior patients. Among these are hospitals, transitional care units (TCUs), and skilled nursing facilities (SNFs). Some clinics also have these programs that aim to ease the transition between hospital and the home.

Some of these programs are catered to different settings. Some focus on the transition from TCU to home. Other programs track senior patients for a month after they’re discharged from the hospital. Most of these programs provide support, typically through phone calls, only for a short period after hospitalization. That means your senior relative may need the assistance of multiple care managers from different providers as they go through the different phases of care transition.

Putting Yourself on the Transition Call List

Another part of the transition is receiving calls from the hospital once your senior relative is discharged. They’ll also receive one after they get home from TCU. If you want to ensure that you’re up to date on all the developments in your senior relative’s care transition, especially if you are charged with their care, make sure that you put your number on that call list.

The calls continue even after your senior relative gets home from the hospital or facility. They can continue for up to three months after discharge, although most end after a month. These calls are a great opportunity to ask questions and clarify concerns you might have while caring for your senior relative.

Understanding In-Home Senior Care

Lastly, care transition programs usually involve personal visits from staff. This happens whether your senior relative is in the hospital, physician’s office, TCU, or even when they’ve been discharged and are settling at home. Just like the other processes, these are time-limited.

However, these visits do not replace home care. There are some in-home care providers that offer more comprehensive and substantial support to provide the best transition possible for your senior relative. It will help restore confidence in your senior as well, helping them regain independence and control in the long run.


Care transitions are incredibly important in ensuring the most optimal conditions for your senior relative as they’re discharged from the hospital. It helps prevent complications, which allows your senior relative to focus on adjusting to life back home. With this guide, you’ll be more prepared to look after your senior relative and ensure they feel more capable and in charge of their recovery.

If you’re looking for transitional care management in McDonough, GA, let us know at Long Life Care Management! We are aging life care professionals with years of experience and have a range of care options available. If you have any questions about the best care transition for your loved one, get a free consultation today!

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