What Is Transitional Care Management?

Transitional care management focuses on helping individuals transition between health care settings. This management system aids in improving health outcomes and ensures clients receive consistent services. 

At Corewood Care, we offer comprehensive transitional care management services for older adults to help our clients thrive and live gracefully. Schedule a free assessment to learn how our services can help an older adult obtain trustworthy support as they transition to a rehabilitation or home setting.

What Is Transitional Care?

Transitional care involves the management and coordination of health services as clients move between health care settings. Typically, clients undergo transitional health care services within 30 days of discharge from a medical facility. The goal of transitional health services is to help clients continue receiving a high level of attention and care to help prevent injury or a need for rehospitalization.

What Is Transitional Care Management?

Transitional care management is coordinating a client’s safe transition from one medical setting to another or to their homes. For transitional care management to be successful, providers, clients and families work together to ensure the transition is smooth while reducing the risk of adverse health outcomes. 

What Sets Transitional Care Management Apart?

The main difference between transitional care management and care management and home health services is transitional services only focus on the period when a client moves from one facility to another or to their home. In contrast, care management and home health services focus on assisting individuals throughout their entire health journey.

Care management refers to a collection of services and activities to help clients with chronic or complex conditions effectively manage their health. While the main goal of health management is to help clients improve their health, it can also include smaller goals, such as improving how the providers coordinate service and enhancing engagement.

Conversely, home health services only focus on caring for a client at their home. With home health services, a client may have health care professionals visit them at their home to provide services.

While a care management plan or home health plan may include transitional management services, it is not the main focus, making it essential to have transitional care management services in place to ensure more complete care.

Is Transitional Care Management Ideal in the Long or Short Term?

Transitional care management is a temporary solution and typically ends after the client reaches 30 days after discharge. Since transitional care management aims to provide a seamless changeover, once a client reaches their 30 days, they are no longer in a transitional period and, therefore, no longer require transitional services. 

Situations Where One Would Need Transitional Care Management

For a client to qualify for transitional care management services, they must undergo a discharge from a qualifying service setting such as a hospital and have a medical record that indicates they require additional support. Some specific situations where an older adult would need transitional management services are:

• Transitions within medical settings, like from a primary provider to a specialty unit
• Transitions between medical settings, like from a hospital to a rehabilitation center or a home
• Transitions across health states, like moving from curative care to assisted living
• Transitions between providers, like moving from a general practitioner to a specialist

Find the Care Your Older Adult Deserves With Corewood Care Today

Having an older adult come home from the hospital or transition to a rehabilitation setting can include many challenges, including a higher risk of falls and medication mismanagement. At Corewood Care, we want to help your older adult be successful during their transition period through our transitional care management services. Schedule a free assessment to learn how our services can benefit you and your older adult.