Care process
Transitional care
Transitional care is support that helps a person move safely from one care setting to another, such as from hospital to home. It includes follow-up contact, medicine review, appointments and coordination. Medicare covers transitional care management services for eligible people returning to the community.
Why it matters for your family
The weeks after a hospital stay carry high risk for confusion, missed medicines and readmission. Medicare says transitional care management services help you return to your community after an inpatient stay at certain facilities, like a hospital or skilled nursing facility. The doctor's office, not a home care company, usually bills for it. It covers contact and a visit with the practitioner. Families often miss the need for daily help at home. A common mistake is to think the follow-up visit covers meals, bathing and rides. Plan for those needs. Non-medical caregivers can assist with daily tasks, reminders and rides, but not medical care.
Source: medicare.gov
Read more: What is Home Care? How to Benefit from These Services?
Related terms
- Discharge planningDischarge planning is the process a hospital, nursing home or other facility uses to prepare a patient to leave.
- Hospital dischargeHospital discharge is when a patient leaves the hospital to go home or to another care setting.
- Care coordinationCare coordination is the work of organizing a person's care across doctors, caregivers, services and family so the pieces fit together.
- Care planA care plan is a written plan that lists a person's needs, goals, tasks, schedule and who does what.
- Medicare Part BMedicare Part B is medical insurance.
- Change in conditionA change in condition is a new or worsening sign in a person's health, behavior or abilities.
