Transitional Care Program

TRANSITIONAL CARE PROGRAM

A Program to support families and children when they need it most.

Definition: Goal: 1

An approved inpatient stay that is needed for a medically fragile child due to disruption in their normal home care.

Provide a home away from home setting for the patient where they are tended to by knowledgeable and compassionate staff.

2

Help maintain and promote a state of optimal wellness for the patient and family.

3

Prevent unnecessary costly visits or admissions to a higher level of care than needed.

TRANSITIONAL

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CARE

PROGRAM

transitional care

Circumstances for a transitional care hospital stay may include:

1. Sudden illness of a caretaker 2. Loss of electricity or another vital utility in the home 3. Family no longer has housing 4. Temporary loss of home nursing 5. Caregivers need education for a new therapy or procedure 6. There is a social problem identified in the home that puts the child at risk 7. Children Youth and Family Services has been called because of suspected abuse or neglect 8. Caregivers must travel and cannot take the child for safety reasons 9. Caregivers have decided that they can no longer care for a medically fragile child 10. End of life care

What can we do to assist the patient/ family during a transitional care admission?

transitional care

1. Review of child’s growth and development 2. Review and adjustment of feedings if needed 3. Review and adjustment of medications 4. Skin integrity assessment and treatment 5. PT/OT review of therapy devices and equipment needs 6. Ensure that all DME supplies are ordered and set up correctly 7. Devise a Nursing care plan 8. Provide a Respiratory care plan if needed

Care

Continuity of Care: 1. Ensure that medical records are sent to the appropriate providers and guardians 2. Social work assessment of post discharge services 3. Homecare nursing staff are welcome to the bedside to review patient care 4. Provide ongoing education for families to ensure they are prepared to care for their child at home 5. Comprehensive discharge planning for patients

help

How does the approved admission help the insurance company?

1. Saves money on unnecessary ER visits and admissions to a higher level of care 2. Less disruptions in home nursing 3. Less children needing long term care facilities 4. Patients have less exposure to other illnesses which could compromise their health and care

help

How does this help the home caregivers be it family or home nursing?

1. Decrease stress on the family and create a healthier home environment 2. Decrease in the maltreatment of children in the home 3. Increase caregivers’ confidence in their ability to care for their children/child 4. Increase job satisfaction and decrease burnout for home care nurses

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