When you or a loved one are recovering from a hospitalization or are being discharged from a rehabilitation center such as a skilled nursing facility, you may need short-term transitional home care. Our nurse-led care and team-focused approach are designed to optimize your health and well-being.

Professionally delivered care can help reduce undesirable outcomes such as re-hospitalization, medication errors and falls; it may even reduce long-term healthcare costs by helping to prevent the health conditions from getting worse.

Why Transitional Care Matters

The transition from hospital to home care can leave anyone feeling vulnerable and in need of support. At BrightStar Care^®, our unique blend of predictive technology and real-time RN oversight addresses common post-discharge risks so clients feel safer and more at-ease during transitional periods.

One of the unique services we offer is Care Paths for Falls and Change of Condition. Although care paths are fairly common, we’ve taken this approach farther by building person-centered and condition-specific Care Paths based on your loved one’s unique needs, current conditions and past medical history.

Using our proprietary technology, our caregivers are able to help predict and prevent a fall or worsening of your family member’s current condition. When a change of condition is identified, we will communicate that information immediately to the supervising nurse at your local BrightStar Home Care and/or your loved one’s physician so any needed action can be taken.

Whether it’s helping prevent falls, avoiding missing medications, or making sure clinical and therapeutic instructions are clear, our transitional care services benefit clients through fewer ER visits and enhanced safety, and provides families with greater peace of mind.

Short-Term Transitional Care Services We Provide

A Registered Nurse (RN) from your local BrightStar^® Home Care oversees the plan of care to help provide a safe transition back home. They’ll actively coordinate transitional care, supervise caregivers, and serve as a communication bridge with physicians.

Our team provides a wide range of in-home services to support a variety of health needs. This combination of hands-on leadership and integration of both clinical and non-clinical services delivers a level of care well beyond what Medicare-only providers typically offer.

Some of the health needs and conditions we support with in-home transitional care services include:

COPD (Chronic Obstructive Pulmonary Disease): We’ll coach proper inhaler use, provide medication reminders and support habits to improve wellness.
Diabetes: We will conduct foot inspections and blood glucose level checks, as well as provide family education.
Heart Attack/AMI (Acute Myocardial Infarction): We’ll provide education and support to develop new lifestyle habits that promote heart health.
Heart Failure: We’ll help manage medication adherence, diet and exercise.
Pneumonia: We’ll provide RN-led medication management, help manage oxygen therapy and offer personal care.
Post-Operative: We will assist with surgical recovery in the comfort of home.
Stroke: We will help with activities of daily living (ADLs) like eating, dressing and mobility, as well as promote fall safety, offer medication reminders and provide transportation to physician appointments or therapy (physical, occupational and/or speech).
Therapy for Post-Op or Stroke: We also have physical, occupational and speech therapists who can provide rehabilitation in your home.*

How Our Transitional Home Care Works

Once you know your hospital discharge date, we begin designing and implementing your personalized transitional care plan. Your BrightStar Care^® care team works closely with your family members and existing medical team. Your plan may include:

Assistance with hospital discharge and transfer to home
Coordinating follow-up appointments
Managing medications
Wound care
Home therapy, including physical, occupational and speech
Personal care services
Companionship support

Our team of professionals puts communication at the heart of our approach to transitional care. We consult with family and caregivers and coordinate with physicians throughout each step of the recovery process.

Filling the Gaps in Transitional Support

Even if your loved one is receiving skilled nursing care from another agency (such as a Medicare-approved group), the companion care and personal care services we offer through BrightStar^® Home Care provides a wonderful supplement. These services can help meet basic needs such as light housekeeping, companionship, family respite, dressing, personal hygiene and ambulation (walking and moving around).

Frequently Asked Questions

Preparing for transitional care can leave you with a lot of questions. But you’re not alone. Our team is prepared to answer any questions you may have about short-term transitional care. Here are just a few of the most common questions we hear from the people we serve.

What is the difference between short-term transitional care and transitional care in hospitals?

Both short-term transitional care and hospital transitional care are designed to help you move safely to a new setting, prevent re-hospitalization due to falls and medication errors, and help with non-medical support. Hospital transitional care tends to focus on the period immediately following transfer to a new setting, while short-term transitional care tends to provide services for a more extended time and can be offered at home. Short-term transitional home care also typically encompasses more holistic services such as personal care and companionship support that may not be available through hospital transitional care.

Why would a family choose short-term transitional care instead of hospital-coordinated transitional care?

Short-term transitional care typically provides services that extend beyond what hospital transitional care can offer. While hospital transitional care focuses on clinical needs during the period just after transition, short-term transitional care usually continues for a longer stretch of time and features a more comprehensive range of support including with activities of daily living (ADLs).

Can short-term transitional care work alongside Medicare transitional care services?

Yes. Even while receiving skilled nursing care from another agency (such as a Medicare-approved group), companion care and personal care services from BrightStar Care® provide a valuable supplement. These services can help meet basic needs such as light housekeeping, companionship, family respite, dressing, personal hygiene, and ambulation (walking and moving around).

Find Short-Term Transitional Care Near You

If you or your loved one would prefer to receive transitional care at home instead of receiving short-term, facility-based care, please call 866.618.7827 or search for your local BrightStar Home Care. We look forward to sharing how we can help.

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*Therapies and other skilled services may vary by location. Please contact your local BrightStar Home Care agency to learn more about their specific service offerings.