MID PHASE
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CARE TRANSITIONS
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SUMMER 2021
W
hen it comes to long-term care, people often use more than one solution over time. As people switch from one type of care to another, there is a transition period. A care transition may occur when someone leaves the hospital and needs support to heal at home after they’ve been discharged from the hospital, or it might happen when someone who is receiving in-home care decides to move into a supportive community, such as assisted living or senior housing. The goal is to avoid a gap in care for the individual as they pivot from care type. When someone leaves the hospital or a rehab facility for home, their doctor or nurse can’t go with them and a family or professional caregiver might be needed as they continue to heal at home. For example, someone might need help with using the bathroom, taking new medications, or going back to see the doctor for follow-up appointments. An even longer and different type of transition may occur when someone decides to move from their current residence to a
