Developing a nursing home transitional care plan

Developing a nursing home transitional care plan

For many nursing home residents, the return to the nursing home after a hospital stay can be all too fleeting. They can often find themselves being admitted to the hospital again shortly after discharge. These readmissions can leave elders susceptible to medication errors, infections and even death. What’s perhaps even more alarming is that of these hospital readmissions, it’s estimated that 60 percent are actually preventable.

So what can nursing home residents and their families do to make the most of hospital treatment while preventing readmissions?

A transitional care plan may be the answer.

One option may be to get a transitional care plan through the hospital where the patient received treatment. When residents receive treatment at select hospitals, they may be paired up with a transition coach, whose leads them through discharge and follows up with nursing home visits and phone calls. This transition coaching is a part of hospital programming that aims to cut down on readmissions.

Another way to get transitional care is through an actual transitional care facility. For instance, residents of Indianapolis-area nursing homes have access to facilities such as Kindred Transitional Care and Rehabilitation in Carmel, Ind. The center provides care programs ranging from short- to long-term care and for conditions such as stroke recovery, diabetes, dementia, lung problems and wound care. Services also include respite care and nutrition therapy as well as palliative and hospice care. Centers such as this will also often offer planning and transitional support as patients get ready for discharge from the care facility.

Yet another option may be devising a transitional care plan with the help of your loved one’s nursing home facility. To explore this option, talk directly with the nursing home to find out the kind of transitional care planning the facility offers.

To help your loved one avoid readmission to the hospital, consider exploring any of these three options.


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