As a loved one transitions from one healthcare setting to another, transitional care providers aim to create continuity through coordination throughout the process. Some individuals have acquired a variety of health conditions that require higher levels of care within a different setting to meet their needs. These transitions occur across the country in hospitals, sub-acute and post-acute nursing homes, the patient’s home, primary and specialty care offices, and long-term care facilities. Well-trained transitional care providers use information from the patient, family and previous healthcare providers to create a comprehensive plan of care that best serves the patient’s needs. Patient and family education, coordination among facilities and other practitioners, and aide with logistical arrangements are included in the transitional care process. It is the complete transition from start to finish which is essential to persons with complex care needs.
Different types of facilities specialize in different aspects of patient care. The diversity of these venues ensure better care and a better experience for the patient. Assisted-Living (AL) facilities provide services focused on maintaining resident independence in a supervised setting. Many assisted living residents live in communities that provide services such as group dining, medication assistance, bathing, dressing, and transportation. Long-Term Care (LTC) facilities are typically incorporated within nursing homes. These venues provide care to patients who can no longer be cared for at home or within assisted-living facilities. These facilities support daily living activities and complex medical problems for patients who require a higher level of care. Physicians will visit patients within these facilities.
As a beloved family member approaches the end of their life, proper care and comfort become the top priority. Skilled nursing care is provided by skilled nurses and therapy staff on a 24 hour basis. Skilled care takes place in a nursing home. Long-term acute care occurs in freestanding facilities or within a hospital setting. These facilities specialize in treating extremely medically complex patients requiring extended hospitalization usually greater than 25 days with access to care including mechanical ventilation. Palliative care focuses on managing chronic conditions of a patient with the goal of providing comfort and the highest quality of life possible. This level of care may be appropriate as a preemptive service to patients who are not yet qualified for hospice care. Hospice care is focused on providing comfort and pain control versus extending one's life for patients expected to live six months or less. This level of care may be provided in an inpatient setting, long-term care setting or in a patient's private residence.