Capital Health Care NetworkThe Value of Transitional Care Planning

We introduced the Home Again Transitional Care Program in March of 2016 in an effort to offset breakdowns in care and communication between providers as our clients moved from acute care settings like hospitals and nursing homes to home. It’s working like a charm! We are experiencing an increase in positive feedback from our clients, a reduction in hospitalizations within our own network and increased trust between healthcare providers inside and outside our network.

Our Home Again Transitional Care Program was developed to help bridge the gap between evidence-based best practices and fragmented approaches to care. The purpose of the program is to ensure safe hand-offs from the acute care providers so that our clients can successfully re-acclimate to life at home. We begin transitional care planning the moment we learn we are going to provide services. Our goal is to provide a smooth transition making for an improved client experience and improved efficiency.

Benefits of Home Again Transitional Care Program:
• Increased Confidence & Communication between Providers
• Reduction in Hospitalization or Re-hospitalization
• Improved Medication Management
• Easy Access to Telehealth & Home Safety Equipment for our Patients & Clients
• Peace of Mind for our Patients, Clients & Families

Our program is based on the idea of a comprehensive plan of care where clinicians and caregivers share current information about our client’s goals, preferences and clinical status. Working across the continuum as a team means we can deliver the kind of top-notch care our clients deserve.

Published By: Lisa Stockdale