Transitional Care

Our transitional care services are designed to support individuals during the transition from hospital to home or from one care setting to another, ensuring a smooth and successful transition while reducing the risk of complications, readmissions, and adverse events. Our interdisciplinary team of healthcare professionals collaborates closely with clients, their families, and their healthcare providers to develop personalized care plans and coordinate continuity of care.

Services Offered:

• Discharge Planning:We assist with discharge planning and coordination, working closely with hospital discharge planners, case managers, and healthcare providers to ensure a seamless transition from hospital to home or from one care setting to another.
• Medication Reconciliation:We conduct medication reconciliation to review and reconcile clients’ medication lists, ensuring accuracy, completeness, and understanding of medication regimens to prevent medication errors and adverse drug reactions.
• Home Safety Assessment:We perform home safety assessments to identify and address potential hazards, barriers, and challenges in the home environment, implementing modifications and interventions to promote safety, accessibility, and independence.
• Post-Discharge Follow-Up:We provide post-discharge follow-up care, including home visits, phone calls, and telehealth consultations, to monitor clients’ progress, address any concerns or complications, and facilitate timely intervention and support as needed.
• Care Coordination:We facilitate care coordination and communication among healthcare providers, specialists, therapists, and other members of the healthcare team to ensure comprehensive and integrated care for clients during the transitional period.
• Patient and Family Education:We offer patient and family education on self-care techniques, medication management, disease management, warning signs of complications, and strategies for promoting recovery and wellness during the transition process.

Additional Information:

– Our interdisciplinary team includes registered nurses, licensed practical nurses, certified nursing assistants, social workers, therapists, and other healthcare professionals with expertise in transitional care management.

– We utilize electronic health records and communication systems to facilitate real-time information sharing, care coordination, and collaboration among members of the healthcare team across different care settings.

– Our transitional care services are guided by evidence-based practices, clinical guidelines, and quality improvement initiatives aimed at optimizing outcomes, enhancing patient experience, and reducing healthcare costs.

– We prioritize continuity of care by maintaining open lines of communication with clients, their families, and their healthcare providers, ensuring that everyone is informed, involved, and engaged in the transitional care process.

Call Helping Hands Senior Services, Inc. at 650-437-2762 for support during your transition from hospital to home or between care settings.