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.
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- 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
- Hospital Discharge Planning Checklist (Robert Wood Johnson Foundation)
- Your Discharge Planning Checklist (Medicare.gov)
- Guidelines for a Hospital Stay: For Patient, Family & Caregiver
- The Care Transitions Program
- National Transitions of Care Coalition - Consumer Information
- Next Step in Care
- Caring From a Distance
- Well Spouse Association
- PACE4You: The Program of All-Inclusive Care for the Elderly
- BeMedWise - Patient Information and Education
- AARP Home Alone Alliance
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)
- PACEFinder: Find a PACE Program in Your Neighborhood
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