Reducing Re-Hospitalization with Home Care

Adults 65 and older are more likely to have a hospital stay than any other age group. In 2019, the hospitalization rate among seniors was 17 percent. Of those hospitalized, the most common reasons for their visit were coronary heart disease, pneumonia, stroke, hypertension, and heart failure. Not only are seniors more likely to get hospitalized, but they're also more likely to get readmitted to the hospital in the first 30 days after discharge. To help reduce re-hospitalization among seniors, Visiting Angels provides transitional care services through our Ready, Set, Go Home program, available as part of our Port Charlotte senior care referral program. 

Transitional Care Services 

One in five Medicare beneficiaries discharged from the hospital gets readmitted within 30 days. Working with a professional caregiver who provides transitional services can work around the needs of seniors undergoing hospital discharge. Our network of trained caregivers works with clients to avoid complications, follow recovery instructions, and get back into the rhythm of their at-home life after a hospital stay. 

Transitional care services start at the hospital or rehab center. Caregivers help clients record essential information discussed in discharge plans with healthcare providers. They then use this information to help clients target areas where they'll require assistance and who will help them, whether it's a friend, family member, neighbor, or caregiver. 

Before discharge, caregivers often visit with the client with a personalized transitional care plan for what will happen in the next 30 days. Caregivers create plans with input from the client, family, and healthcare providers to ensure all individual needs are met. Professional caregivers can then assist in transporting the client home and help them get comfortable in their space. 

The caregivers we refer to can assist clients with non-medical tasks throughout the transitional care to help them feel safe and secure at home. These activities may include light housekeeping, meal preparations, personal grooming, and medication reminders. Caregivers can also provide transportation to follow-up appointments and mobility assistance to make moving around the home more accessible. 

While at-home caregivers don't provide medical assistance, like dressing wounds or administering medications, they can give clients reminders to follow specific follow-up care instructions. They will communicate with the family if additional steps are needed to ensure the client's recovery.

Getting Started with At-Home Care

All new clients can schedule a complimentary consultation with our referral specialists to ensure transitional care services are the right match. During the initial meeting, our team will give new clients an in-depth look at the services included in transitional care and how they can assist the client. This consultation is also a time for clients to share personalized needs and ask questions to learn how an at-home caregiver will fit into their road to recovery, whether they need respite care, short term care, or long term.  

After the initial meeting, our team will refer you to a group of caregivers with the appropriate training and experience to select. Once the clients find the right fit, seniors and caregivers will work together to build a personalized transitional care program. Seniors and their families have the final say in caregivers and are free to accept or reject referred caregivers. 

Our Northport office serves those in Northport, Venice, Port Charlotte, Nokomis, Punta Gorda, and the surrounding communities. Seniors interested in learning more about at-home care services or scheduling their complimentary consultation can call us at 941.496.9600. We also provide referrals for companion care near you.