Frequent transitions between various care settings are what chronic disease patients have to go through. One cannot stress enough the importance of accurate information exchange during the transition of care from hospital to home.

If you are rapidly moving between care settings, it’s time that you get introduced to transitional care coordination. While returning to your abode gives you a sigh of relief, the worst may not be over yet.

According to Forbes, about 20% of Medicare beneficiaries go through readmissions within 30 days of getting discharged from the hospital. This unfortunate statistic is the consequence of loopholes that exist in the country’s healthcare system.

This is where the role of transitional care becomes crucial.

What is Transitional Care Coordination?

When patients are discharged from a care facility, they require assistance in the day-to-day routine and care continuity. Transitional care coordination thus promotes timely and safe movement across care settings.

Transitional care management is an extension of the services to expedite the patient’s recovery by providing rehabilitative care. The purpose of transitional care is to restore the patient’s independence – up to a certain level. Transitional care looks after the following:

  • Dietary planning or nutritional counseling
  • Wound care
  • Frequent laboratory tests
  • Occupational, speech, and physical therapy
  • Respiratory therapy and ventilator care
  • Fall prevention
  • Intravenous anticoagulation therapy

Transitional care management, on the other hand, involves managing frequent passage between care settings.

Transitional care coordination thus dramatically simplifies things for the patient as well as their caregivers.

Transitional Care Can Reduce Hospital Readmissions

While the primary benefit is easing transitions between different levels of care, another key benefit of transitional care is reduced hospital readmissions. Naturally, the costs associated with frequent admissions also decrease.

It sets the stage for the subsequent stage of recovery for you or your loved one. Without transitional care, the chances of missing your appointments could amplify.

Even if you adhere to appointments, it can get quite overwhelming to live in a stressful situation continually. This is why transitional care coordination is vital for the patient and their caregiver’s mental and physical well-being.

The Decrease in Level of Anxiety

When patients know what to expect after the transition, they are no longer forced to worry about what may happen next.

It leads to a significant reduction in stress and anxiety as a result. Seniors can spend more time with their family instead of spending extending periods at hospitals.

Who Are Transitional Care Coordinators?

Readjusting to the home environment or a different care setting is not easy. You may have a lot of questions about your new medications or a new routine. Transitional care coordinators are responsible for managing home health care before you are discharged from the hospital.

They can answer any questions that you may have and assist you in various areas of need. Some of them include transportation, emotional issues, social issues, medication, medical equipment, and meals.

Transitional care coordinators also educate the patients and their families about what’s best for them in the current scenario. Hence, transitional care coordination fills the gaps that exist in care settings, providers, and services.

Elimination of Medication Errors

According to the World Health Organization, over 40% of medication errors occur due to improper reconciliation in handoffs during discharge, transfer, and admission. In almost half of these cases, it results in significant harm to the patient.

Chronic disease patients are generally on multiple medications. If not handled properly, it could become a safety issue for the seniors. Therefore, the transition of care for the elderly also involves medication management.

Any changes in the patient’s medication are also updated in their electronic health record (EHR). That way, both caregivers and the patient can stay updated, thereby minimizing the probability of drug interaction.


Change is difficult, particularly for someone who has been diagnosed with a chronic disease, is recovering from an illness or surgery. Seniors are emotionally and physically vulnerable, and frequent transitions make their condition even more challenging.

A lot of information about their care is disseminated in a relatively shorter time of appointments. When the patient’s ability to comprehend everything is compromised, transitional care coordination can bridge the information gap.

If you or your loved one require transitional care coordinators, visit our website or call +1 800 395-2065!

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