Care Transitions

Issues to Consider

Be vigilant.

When a family member moves from one care setting to another—say, from the hospital to home or a rehab facility, or rehab to home, you need to be vigilant. It is a time when many people wind up back in the hospital because of poor communication, shoddy coordination or medical errors.

Hospitals can be vague in their discharge instructions about the care required at home, directions might be complicated, or a patient may be confused about medications or not know that a medication can have severe side effects.

Speak with a transition coach.

Some hospitals have transition coaches or care transition coordinators who help patients move between different care settings, keep professionals and families in the loop and advocate for the patient. There are also community-based organizations that may partner with hospitals. Ask your hospital, rehab or long-term care setting what they offer.

What to ask.

Here are some questions that you should have clarified before your parent moves from the hospital or rehab to home:

Dad’s regular doctor may not even know he has been in the hospital or rehab, or about new medications prescribed.

Take notes.

Write down everything in a notebook, online and/or in a Personal Health Record booklet that can help you organize information. This includes updated medication dosages and pills, how Mom is feeling and any questions either of you may have for the doctor. Your parent needs to share their Personal Health Record at all medical visits and with the pharmacist.