Transitional Care

Care Transition

Transitional care is the care that happens when a patient moves from one care setting to another. This can be moving from a lower level of care to a higher level of care or vice versa. For example, moving from an acute care hospital stay to a nursing home or transitioning from an assisted living facility to inpatient acute or long-term care. However, this can also mean progressing from having home health in the home to only being followed by a primary care provider or being referred to other providers.

Optimum Care Hospitalist Group attempts to achieve transitioning patients with the highest level of attention by collaborating and coordinating with the entire healthcare team including the patient, families, nursing, case management and providers, to transfer patients between health care entities, providers and settings with the least amount of distress and the best outcomes for the patients and their families. Well-trained staff and providers obtain these high-level outcomes by focusing on patient goals, preferences, clinical status and educating the patient and family. 

Transitional care refers to the coordination and continuity of health care during movement from one healthcare setting to another or to home, called care transition, between health care practitioners and settings as the patient's condition and care needs change during the course of a chronic or acute illness. Older adults who suffer from a variety of health conditions often need healthcare services in different settings to meet their many needs. For young people, the focus is on moving successfully from child to adult health services.

 Services available during transitional care:

  • Comprehensive rehabilitation
  • Restorative nursing
  • Physical, occupational and speech therapy
  • Nutritional care planning
  • Advanced wound care programs
  • Intravenous (IV) therapy
  • Short and long-term care