A New Hospital to Home Transitions Program

Dorothy’s most memorable line from the Wizard of Oz, “There’s no place like home” remains etched in our minds because there’s truth in it. While going home is comforting to most people after they’ve been hospitalized, getting settled at home can present a few challenges. While a relief to be home, it can still be scary or overwhelming at the same time.

Transitions to Home 1

There’s No Place Like Home

Family Caregivers Network understands the first few hours after discharge from the hospital or rehab are critical to your recovery. Immediate personal care needs may be more than a patient or their family can handle alone. Our new Transitions to Home program bridges the gap between hospital to home for recently discharged seniors. Statistics show that seniors who are discharged from the hospital who are then quickly readmitted is due to two reasons; lack of follow through with after care doctor appointments and medication mismanagement. A Hospital to Home government resource booklet helps families plan for discharge, which is a start. Family Caregivers Network’s Transition to Home program goes above and beyond to help you make the discharge plan.

Family Caregivers Network assists families to meet the needs of their loved ones post discharge. Educating the family, case workers, and social workers is part of what we do to understand why those first few hours home are so critical. The services provided to assist in the transition to home include transporting an individual home from the hospital when a family member cannot be there, getting medications filled from their local pharmacy, grocery shopping and preparing meals for the first 24 hours home, preparing linens for bed and bathing as needed. We also schedule the follow-up doctor appointments and communicate the arrangements with family members. Special arrangements can be made for a nurse to pre-fill the individual’s medication planner.

Our Care Managers coordinate the hospital discharge with the hospital discharge team so patient’s have a seamless transition to home. 24 hours after discharge a follow-up call by our Care Managers is made to the client to ensure their safety and care needs are being met. All Transitions to Home visits are scheduled in 4 hour, 6 hour, or 8 hour blocks of time.

For more information about the Transitions to Home please call the Family Caregivers Network office at 215-541-9030 to speak with one of our Care Team Members.

Transitioning home is not always easy after a hospitalization. There is so much to remember; what the doctor wants you to do, medications to pick up from a pharmacy, getting your home prepared with food, preparing meals, linens for bed and bath, etc. Our New “Transitions to Home” program helps seniors by reducing the stress of discharge and ensure a safe return to home.

Statistics show that seniors who are discharged from the hospital can be quickly readmitted due to two main reasons: lack of follow through with after cares doctor appointments and medication mis-management. We understand the first few hours home after a hospitalization is critical to your recovery. Family Caregivers Network provides safe, reliable transportation home, a re-acclimation to your home environment, and high quality care for your loved one.

The Goals of the Transitions to Home Program is to:

  1. To reduce avoidable readmission to hospital or rehab.
  2. Provide families with a fully coordinated transition to home.
  • 3. Reduce stress and provide peace of mind with transition to home.
  • 4. Billed in 4 hr, 6 hr, or 8 hr. shifts.
Transitions to Home 2
Services may include:
  • Follow up prior to discharge
  • Transportation to home
  • Pharmacy/medication pick up
  • Medication pre-setup plan by nurse as needed
  • Grocery shopping and dietary meal plan
  • Schedule follow up doctor appointments
  • Meal prep for first 24 hours
  • Prepare living environment/bedroom linens
  • 4 hour, 6 hour, 8 hour payment options
The “Transitions to Home” program can alleviate the stress associated with a recent illness and hospitalization.

Ongoing assistance at home is also available to with short term or long term care. All caregiving staff have gone through a Family Caregivers Network certified training program and are bonded and insured. For more information on the Transitions to Home program and other services offered by Family Caregivers Network call 215-541-9030.