Council on Aging Answers 2016 - 16

COUNCIL ON AGING - ORANGE COUNTY

HEALTHCARE

Transitional Care: Helping To Avoid Readmission
and Heal at Home After Being In The Hospital
n Rani Khetarpal
Transitional Care is a new Medicare benefit that helps
patients who have been in the hospital avoid complications and readmission once they have been discharged
home. Global Transitional Care offers continuous clinical oversight via a Nurse Practitioner and Registered
Nurse, after you have been discharged from the hospital,
during the 30 day high risk period of readmission. Global Transitional Care differs from home health and works
alongside your home health nurse to not only monitor
your healing process, but to also be your advocate to
ensure you have the resources you need to heal at home.
How do patients access Transitional Care?
As an approved Transitional Care Medicare provider,
patients can self-refer - no physician referral is needed.
Physicians and surgeons, case workers, rehabilitation
hospitals and nurse navigators can directly refer patients

16

Answers Guide 2016	

to a Transitional Care provider as well.
A Transitional Care Nurse meets with the patient and
their family when they are in the in-patient facility, just
before discharge, so that everyone can understand the
patient's needs. Once a patient is aligned with a Transitional Care provider, they are assigned a Transitional
Care team, which includes a specially trained Nurse
Practitioner and Registered Nurse. The Transitional
Care team works directly with the patient to manage
their health needs, as well as coordinating with their
physician and other related professionals such as physical therapists and home health nurses.
The patient has access to their Transitional Care team
24 hours a day/7 days a week for a period of 30 days.
This includes both phone and face-to-face visits between
the patient and their nurse. In addition to clinical oversight, a Transitional Care team provides an extensive
level of care coordination, medication reconciliation and
disease management education.

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http://www.globaltransitionalcare.com

Table of Contents for the Digital Edition of Council on Aging Answers 2016

Contents
Council on Aging Answers 2016 - Intro
Council on Aging Answers 2016 - Cover1
Council on Aging Answers 2016 - Cover2
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