Melissa Powell

Transitional care — a set of actions put in place when a patient leaves a hospital or skilled nursing facility — is a vital part of the care journey and one that has increased in importance as more and more Americans over the age of 65 have expressed a preference for aging in place. 

How can they get the proper care as they return home, especially given the prevalence of chronic conditions among those in that age demographic? A comprehensive plan is critical when making this transition. 

A report from CareCentrix, a national home-based healthcare organization, illustrates why the trend toward care at home is in the best interests of both patients and insurers. Seventy-two percent of all respondents would prefer to recover at home versus a medical facility following a major medical event; 69%would prefer regular, at-home check-ins with doctors; and 63% would rather receive treatment at home over going to a doctor’s office or medical facility. 

Not only that, but almost all the payers who responded agree that home healthcare is in the best interests of insurers and patients alike, and close to the same number believe that treating seniors at home is more cost-effective in the long run than treatment in an SNF.

The COVID-19 pandemic has compelled many healthcare organizations, large and small, to invest in technology that has allowed patients to receive remote care, one prominent example being the increased use of telehealth. But John Driscoll, CEO of CareCentrix, noted that it also revealed that home-based patients need an organization like his to “provide the support, the management and the follow-on care to make sure patients aren’t lost.”

As hospitals were overwhelmed by a surge of patients in the early days of the pandemic, telemedicine became increasingly valuable both in easing the burden on burned-out caregivers and allowing patients, especially those less ambulatory, to receive care at home. 

According to NPR, the trend toward shifting elder care into home care began even before the pandemic. And because the number of Americans over 65 is expected to double by 2050, government officials and healthcare providers alike have been investigating methods to reduce the costs of caring for seniors for more than a decade. 

That seniors overwhelmingly want to age in place “has underwritten the development of long-term care services really for about the last 25 years,” according to Kevin Hancock, deputy secretary of the State Department of Human Services’ Office of Long-Term Living.

AARP offers the following tips on helping older individuals and their families making care transitions: 

  1. Researching hospitals, SNFs and assisted living facilities in the immediate area ahead of time and talking with aging loved ones about their preferences and wishes — specifically about where they want to be treated, recover and live — is a good idea. Medicare offers ratings and reviews of Medicare-certified facilities.
  2. When deciding whether to seek out a healthcare facility or to make the transition to home-based care, it’s important to visit the facility or facilities to review what care resources are available and to evaluate cleanliness, meals, residents, certifications, costs and insurance coverage. When considering home care, it’s critical to understand what insurance does and doesn’t cover, and what arrangements need to be made for home modifications, medical equipment, personal and medical care, physical and occupational therapy, meal delivery, transportation, and the availability of remote care and monitoring. Hospital discharge staff and social workers can help in planning transitional care.
  3. Communicate clearly with hospital or SNF staff to ensure medical records (which are often in an electronic format now) and other critical information about treatment, medication, and specifics about the patient’s condition is shared with home healthcare aides and/or family members. Research shows that patients do better with follow-up care when a family caregiver is present to make a note of discharge instructions. Home-based caregivers are often expected to perform follow-up medical procedures, so some instruction before a patient is discharged is absolutely essential.
  4. Sometimes healthcare facilities are unrealistic about what setting is best for a patient and what their family can handle, especially in terms of future care. Speaking with care managers and providers and constructing a team of family members and friends who are available to offer support can take some weight off primary caregivers. 

A recent study revealed that those receiving transitional care were nearly twice as likely to avoid readmission to hospitals or emergency departments, and among residents of long-term care facilities, two-thirds of hospitalizations are potentially avoidable when patients receive high-quality transitional care.

The report’s authors concluded that it is “therefore essential to invest in transitional care interventions” but added that “investment in such interventions has been remarkably low across most countries.”

Moreover, they added:

“Quality transitional care has several dimensions, including communication between healthcare professionals around discharge assessment and care planning, preparation of the patient and caregiver for care transition, timely and complete exchange of information between all parties (staff in different settings, patients, family caregivers), staff training, and patient and caregiver education on self-management.”

As the saying goes, “Home is where the heart is,” and for aging Americans, home is where they want to stay. At the same time, they often need a helping hand. And that’s where transitional care comes into play.

Melissa Powell is the executive vice president and chief operating officer of Genesis HealthCare. She was previously president and chief operating officer of The Allure Group, a New York City-based nursing home operator. Melissa has 20 years of experience coordinating, assessing and improving senior care utilizing a market-focused model in New Jersey and New York.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.