Home Care Transition Considerations And Basics To Follow

After post-acute care or surgery, there are two options open for you for the aftercare process. Either you stay in the hospital or a nursing home and pay for the additional bills or arrange for a home care service and save a considerable amount on your aftercare expenses.

Ideally, this is the transition period that needs continual care and attention from a trained and qualified nurse. Most of the people o for hiring such services from a reputable agency for the Homecare jobs that involves a wide and diverse range of services such as professional contact with not only the patient and their family members but also with several other players of the home care industry such as:

  • The physicians
  • The hospitals or nursing home facilities
  • The senior living communities
  • Different social groups
  • Several professional associations
  • Other health groups and institutions and more.

The home care provider or the nurse will appraise all of them of the current situation of the care process, the condition of the patient as well as the availability of the care services from the agency.

Additional jobs have done

In addition to that, they will also integrate different clinical and medication guidelines and protocols. They will also study different other metrics that will help in the development of a proper and most effective care transition plans for the particular patient. These patient-centered care plans will ensure the promotion of the quality of life of the patient as well as the efficiency in the delivery of the care services.

That is not all. Apart from the above duties, it is also required by the home care professionals to look after other things such as:

  • The external transitional care activities
  • Home health and environment
  • The strategic relationships with the health systems
  • Hospital and other inpatient facilities
  • Be in touch with the physicians and physician groups and
  • Perform several other executive-level opportunities.

The transition nurse or home aide will ideally act as the most effective and efficient public awareness representative for the home health care agency.

Skills required 

It is the transitional nurse who will be responsible for educating the informal caregivers in the family about the hospice services provided and required. They will need to monitor the execution of transitional care services and ensure quality assurance. This will also be done through visits with different entities as applicable and other referral sources as well.

All these need exceptional skills, proper knowledge of the goals to meet and follow the set standards of the care process so that it gets approval from the senior management. Apart from having the relevant license, training, and accreditation, the nurse should also have:

  • A strong understanding of the needs of the customer
  • Knowledge about the market dynamics as well as its requirements
  • Exquisite knowledge about transitional care and home health
  • Excellent communication skills with groups and individuals
  • Ability to organize, plan and execute programs
  • Ability to prioritize multiple tasks
  • Ability to meet the given deadlines and produce the results with minimal supervision.

In addition to that, they must also have adequate knowledge about the Federal, State, and local laws and different complex regulatory guidelines that govern home health care and hospice service.

Know the implications

Every family caregiver, who is also termed as informal home caregivers, should have proper and adequate support in order to ensure that the care services provided are just as required and as per the set standards.

There are different implications for support of the family caregivers though, in this industry, there is a limited focus on them. However, if you go through different studies conducted on the caregivers you will come to know about the different key elements that help to improve care transition and at the same time enhances the support of family caregivers. These elements are:

  • Needs, preferences, and goals of patients and their family members
  • The evidence-based protocols
  • The utilization of the interdisciplinary teams
  • Enhanced communication among the patients, providers and family caregivers
  • Utilization of the information systems in the best possible way such as the EMR or electronic medical records across the entire traditional setting and
  • Designing better and more effective family-focused care

Though there is a need for such knowledge for the caregivers, the study findings suggest that family caregivers lack such knowledge and skills. In addition to that, the barriers and lack of significant resources will affect proper transitional care.

Creating proper performance measures

It is only when you have early identification and knowledge of the health issues of the older patients you will be able to design proper treatment plans. Sometimes, the lack of skills of the family caregivers and access to a health professional will prevent them from responding to the questions and concerns regarding the care plan in a timely manner.

  • In order to address these issues, it is needed to make new investments so that the informal caregivers know their roles and exactly what they need to do during critical transitions.
  • It is also required to conduct a comprehensive assessment of the needs and abilities of each of the caregivers so that they can perform the right way at the right time.

Most importantly, they must be provided with the right tools and given more time to coach them about family caregiving.

Knowing the regulatory reform

In addition to all these, adequate and proper knowledge of Medicare regulations is also required by the caregivers so that they can easily promote the care system as required by different providers like:

  • The hospitals
  • Home health care agencies or
  • Skilled nursing facilities.

These rules govern every aspect of caregiving such as delivery, tracking and monitoring the progress as well as charging for the transitional care services. This will ensure that there are no gaps left in the care process.

Ideally, these regulatory barriers are designed with the intent to deliver the best and most evidence-based transitional care focusing on the need of both the patients as well as the family caregivers.

These regulatory measures also focus on the proper alignment of incentives to the caregivers through timely and adequate reimbursement that will promote the transitional care process.


What do you think?


Leave a Reply

Your email address will not be published. Required fields are marked *

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.



It is better to play in an free online casino slots room (

Learn to play jumpman slots: The buy gamble (