Transitions in Care
- Care transitions occur when an older adult moves from one care setting or level of care to another.
- One typical care transition is when there is a hospital discharge to nursing, rehabilitative, or home care.
- Care transitions can be difficult and stressful for both the patient and the family caregiver.
- Communication between health providers and family caregivers is important to ensure smooth transitions.
- Care coordination can help make sure that the patient's needs are met during and after the care transition.
- Family members and caregivers can find the resources and information they need to connect with appropriate care transition supports and services.
We’re here to help. Please let us know if you have a question or feedback by emailing info@seniornavigator.org. Be sure to include your city, county, or zip code so we can better meet your needs.
Key Articles
- Meeting the Challenge of Care Coordination
- Geriatric Care Managers Can Help Busy Caregivers
- The Emergency File Every Caregiver Should Create
- Make a Medical Plan and Hospital "Go Bag" During COVID-19
- What Every Family Should Know About the CARE Act
- Family FAQ: Skilled Nursing and Rehabilitation Facilities
- Medicare's Nursing Home Compare
- Programs of All-Inclusive Care for the Elderly (PACE)
Tip Sheets & Tools
- Next Step in Care: Guides and Checklists for Family Caregivers
- Your Discharge Planning Checklist (Medicare.gov)
- Guidelines for a Hospital Stay: For Patient, Family & Caregiver
- AARP Home Alone Alliance Resources and Videos
Stay Connected
- National Transitions of Care Coalition - Consumer Information
- Next Step in Care
- Well Spouse Association
- PACE4You: The Program of All-Inclusive Care for the Elderly (National PACE Association)
- BeMedWise - Patient Information and Education
Visit the AgingCare Caregiver Forum to interact with other caregivers!
Your Local Programs
- Virginia Area Agencies on Aging
- No Wrong Door Virginia (Access-Options-Answers)
- Virginia's Program of All-Inclusive Care for the Elderly (PACE)
- Virginia Pace Alliance, Inc.
- PACE Sites in Virginia
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