NAVIGATING CHANGE
Ensuring Continuity of Care
Chronic conditions require consistent monitoring and management. At Quality Life Services our Family Home Health services offer continued in-home care for those who are able to recover at home, or our skilled nursing facilities provide necessary support for those with conditions that require additional monitoring and care.
Dementia, heart disease, COPD, diabetes, and other chronic conditions can often be managed in the patient's community setting. When there is an interruption in care while the patient is being transitioned from inpatient to in-home care or a care facility, it puts the patient at risk for relapse and increases the risk for readmission. Transitional Care Management (TCM) exists to ensure continuity of care during this transition period. By taking responsibility for the patient's health during this time with a focus on facilitating a successful transition, TCM can dramatically reduce the likelihood of readmission. TCM services generally fall into three categories: Interactive contact; Non-face-to-face services; Face-to-face visits.
Contact should be made within two business days following discharge of the patient from the hospital. This initial contact is intended to address the status of the patient and their unique transitional needs.
How We Support a Smooth Transition in Your Loved One's Care
At Quality Life Services, we understand that leaving the hospital can bring new questions and challenges. Our team helps coordinate the next steps in your recovery, ensuring patients and families have the information, resources, and support they need for a safe and successful transition.
Reviewing Hospital Discharge Instructions
We help review discharge summaries, care plans, and important medical information to ensure a clear understanding of the patient's ongoing healthcare needs.
Coordinating with Healthcare Providers
Our team works with physicians, nurses, and other healthcare professionals to support continuity of care and arrange appropriate medical services following hospitalization.
Identifying Ongoing Care Needs
We help assess the need for continued treatments, diagnostic testing, rehabilitation services, and follow-up care to support recovery and overall well-being.
Assisting with Follow-Up Appointments
Coordinating necessary medical appointments and follow-up services helps patients stay on track with their recovery plans and may reduce the risk of avoidable hospital readmissions.
Providing Patient and Caregiver Education
We offer guidance to help patients, families, and caregivers understand treatment plans, manage daily activities, and feel more confident navigating care after discharge.
Supporting Medication Management
Our team assists with medication coordination, prescription needs, and understanding medication instructions to promote safety and consistency throughout the recovery process.
Questions About Your Next Steps?
The transition from hospital care to home or a skilled nursing facility can feel overwhelming, but you don't have to navigate it alone. Our admissions team is here to answer your questions, explain available care options, and help you determine the next steps for yourself or your loved one.
Call our admissions team at 888-835-4557 for personalized guidance and assistance with care transitions.
Find a Location with Care Transition Services
Explore Additional Senior Care Services
Skilled Nursing & Rehabilitation
Our skilled nursing and rehabilitation services provide personalized medical care and therapy to help patients recover after a hospital stay, regain independence, and return home safely. Short-term stays are often covered by insurance.
Assisted Living & Personal Care
Our assisted living and personal care services provide personalized support with daily activities, including bathing, dressing, and medication management. Residents enjoy a comfortable, supportive environment with attentive care that encourages independence.
Home Health Care
Family Home Health provides professional in-home nursing care, rehabilitation, and supportive services to help patients recover and maintain independence in the comfort of home. Most services are covered by insurance.
Hospice Services
Three Rivers Hospice provides compassionate end-of-life care, offering comfort, dignity, and support for patients and families. Services are available at home, in personal care communities, or in nursing facilities, with coverage through Medicare and most insurance plans.
