What Is Transitional Care and How Is It Different from Home Care?

Whether you're a senior or a family caregiver, a hospital discharge involves a number of tasks that can feel overwhelming, from paperwork to follow-up appointments to receiving healthcare advice. While a senior may have managed well on their own before a hospital visit, they might suddenly need more support from family, friends, and professionals. Transitional care is a great choice for families navigating post-hospital time at home who find they need temporary support.

Transitional care can help smooth the transition back to home life for seniors and caregivers. It also ensures continuity of care from the hospital stay to home, which may reduce potential hospital readmissions and improve outcomes for the patient. Seniors with multiple chronic conditions, those recovering from significant hospital stays, or who experience cognitive or mobility issues especially benefit from this type of care. Transitional care can also help you understand if a loved one would benefit from long-term in-home care.

Below, we cover what transitional care is and what sets it apart from other types of home care. Decide if transitional care is the best fit for your loved one's needs.

What is transitional care?

Most family caregivers are familiar with at-home professional care as a form of ongoing support for a senior in their own household. Transitional care is just a different variation on this setup, meant to support your loved one after a more disruptive event, like a stay in the hospital following an injury, illness, event (such as a stroke) or planned surgery.

Transitional care is part of the coordination between families and medical facilities, typically hospitals, as seniors return home. Transitional care may also be necessary if a senior is moving from a hospital to a rehab center or other specialist facility before being allowed to return home.

After the stress of the hospital, some seniors may need time to reacclimate to their usual environment and regain confidence in their strength and health. Transitional care offers assistance as they get back into their routines and support as they work to regain independence. The added care also gives family caregivers an opportunity to recalibrate and avoid the caregiver burnout that can come after helping a loved one navigate a hospital stay.

As part of post-hospital care, a transitional care provider may provide:

• Medication reminders
• Help picking up prescriptions
• Support following discharge instructions
• Attending follow-up appointments with your loved one
• Transport to follow-up appointments
• Meal preparation
• Mobility assistance
• Support with personal care and daily routines
• Companionship and support for you and your loved one
• Encouragement and support throughout the initial period of doctor-prescribed physical or speech therapy
• Basic personal hygiene support to help get dressed and ready every day
• Light housekeeping to keep the home environment clean, tidy, and safe from any hazards

How transitional care supports the move from hospital to home

Families seek transitional care for various reasons, but most often after a significant or unexpected event that leads to hospitalization. Sometimes they're able to prepare, sometimes they're not, and assistance as they recover can make a huge difference in stress levels and health. Some reasons families might seek transitional care include significant injuries that require more help than your loved one previously needed, a demanding work schedule that makes it harder to take time off to be at home, or if you simply feel your loved one would benefit from the extra support are all valid reasons to look into transitional care.

Helps you plan ahead

Hospitals are familiar with transitional care and can often help you make decisions with support from a discharge nurse or social worker. They should be able to assist in finding an appropriate in-home transitional caretaker, as well as setting up medical or rehab appointments like physical therapy. They might assist with discharge planning, including checking on medical equipment deliveries and set-ups at home.

Hospitals may also have a discharge team that can offer guidance on setting up a space at home for recovery that supports practicality, hygiene, and safety.

Transitional caregivers are often trained to notice aspects of a home that may not have been issues for a senior before a hospital stay, but now need adjustment through recovery. They can identify potential tripping hazards or lighting issues in the household, helping to decrease the risk of falls and hospital readmissions.

Keeps the first days at home organized

After a hospital stay, the recovery period has some common challenges that family caregivers may not have had to navigate before. Professional caregivers are there to offer support and guidance through the process of getting a loved one settled after their hospital stay. Common issues that crop up are misunderstanding medical instructions or forgetting or mistiming new medication.

Transitional care helps avoid these pitfalls. A transitional caretaker can keep prescriptions organized and help with adherence to physician-prescribed diet or exercise regimens while helping your loved one stay comfortable and connected. For family caregivers who also work full-time, this assistance is even more important. A professional caregiver can offer peace of mind and help families take the breaks they need to avoid caregiver burnout.

Provides support through the first weeks after a hospital stay

In the weeks following a hospital discharge, there are often many new responsibilities. There will likely be follow-up appointments and many adjustments to a regular routine. Recovery moves at a different pace for every senior, and without the right support, it can feel slow and isolating.

Transitional care offers seniors companionship and assurance through what can be an emotionally challenging time.

Transitional healthcare professionals are often well-versed in the entire process of at-home help after a hospital stay. That includes understanding the services that might be helpful and providing you with connections to broader care teams at the hospital, including specialists, nurses, doctors, physical therapists, and social workers. Their advice and guidance can make the process easier to understand for you and your loved one.

Transitional care vs home care: what's the difference?

For some seniors and their families, a transitional caretaker may be their first experience of at-home professional help. But there is a difference between transitional care and other types of home care:

• It is intended for specific transition periods, such as coming home from the hospital. Home care is often long-term, for those who need regular support at home.
• Transitional care supports recovery, getting back into routines, and regaining confidence after a hospital stay. Home care often focuses on comfort, independence, and connection in a longer-term sense.
• Transitional care is built around recovery goals, while home care is more personalized around preferences and lifestyle.

The most significant difference is in timing, intensity, and purpose. Though transitional care is a type of home care, the purpose differs from services like respite or Alzheimer's and dementia care. Transitional care can also become long-term at-home care if you find your loved one needs more ongoing support.

How to tell if a loved one needs ongoing home care after transitional care

As the transition period comes to an end, some seniors may feel fully recovered and ready to get back to totally independent living. Others may find that continued support is what they need to settle into their new baseline following a hospital stay.

The need for ongoing care is not a setback. It can be a positive step in improving the quality of life for both seniors and family caregivers who need the extra support. Ongoing at-home professional care allows families to set their own recovery schedule after the initial post-hospital period has passed. Every senior's care needs are unique to their journey, and long-term care is designed to accommodate these.

Some signs a loved one needs ongoing home care after transitional care include:

• Continued mobility issues

• Challenges meeting a new healthcare regimen or remembering to take medication
• Difficulty with daily tasks, such as bathing or cooking independently
• Difficulty performing housekeeping tasks due to fatigue or other symptoms
• Social isolation or withdrawal
• Ongoing follow-up appointments that might be difficult for family caregivers to track or attend without support

It's also important for family caregivers to assess their own needs during this time. Ongoing professional care at home may help with symptoms of caregiver burnout after transitional care. Consider everyone's routine as the transitional care period comes to an end.

Transitional care FAQs

How long does transitional care usually last?

After the initial hospital discharge, most transitional care lasts for around 30 days, though this can vary from person to person. Planning for transitional care will likely begin while the loved one is still in hospital, as families and the hospital teams coordinate safely moving a senior to their household. The care ends after several weeks, when a full recovery or significantly improved mobility and independence is seen.

If at the end of a transitional period it seems like your loved one needs more help, they may choose to extend to ongoing home care.

Is transitional care covered by insurance?

Certain types of care are covered by Medicare, such as home health care, physical therapy, and occupational therapy. However, home care in general is not covered by insurance.

Insurance plans can vary and every individual will need to check with their relevant provider. In general, the first 30 days of transitional care may be covered by Medicare Part B, while private insurance may require pre-authorization in order to cover transitional care costs.

To learn more, review the references on the Medicare website or check with your provider to be certain what can be covered.

When should transitional care planning start?

It's helpful to understand what is available through insurance for transitional care as soon as possible into a hospital stay, especially if it's a planned admission.

Families should check with their healthcare providers and insurance to understand what is possible in terms of coverage. This research should be part of a larger care plan put in place for the first day of discharge.

Find compassionate support through every transition with Comfort Keepers^®

Transitional care is a powerful way for families to feel supported as seniors find their way back to normal following a hospital stay. At Comfort Keepers^®, we provide personalized post-hospital care for seniors who may need additional everyday support after returning home after a discharge. This can complement transitional care services like home health, physical therapy, and occupational therapy, helping your loved one feel supported emotionally as well as physically.

Comfort Keepers can also offer other types of in-home care that can be arranged according to the loved one's progress and ongoing needs. We don't just support recovery physically. We look for moments of connection and joy to help seniors feel like themselves again. Reach out to a local Comfort Keepers^® team to discuss how we can help support your loved one.