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Transitional Care, an Important Lifesaving Tool

Tom Arnold reflects on transitional care

Last week I attended three meetings all with a similar agenda, transitional health care. The meetings included a small group at the (AHHC) Association for Home & Hospice Care of North Carolina representing home care, home health and hospice and the role home care plays in the care transition process. Also I was a guest at Wake County Medical Society Community Health Foundation steering committee's meeting to observe discussion from the advisory board on health care access in Wake and surrounding counties. The third meeting I attended was the Care Transition Coalition of Wake County.

Senior Driving.

At these meetings were representatives of area hospitals, rehabs, senior living communities, non-profits, home care, health care & hospice, pharmacies, etc. etc. etc. A representation of transitional care from cradle to grave. It became obvious to me there were two parallel conversations going on; one based on reducing the cost of health care and another conversation on reducing re-hospitalizations and frequent trips to the ED. Ultimately both conversations have an impact on the other.

  • Why is transitional care important and what is it?
  • What does the term "care transitions" mean?
  • Why are hospitals interested in care transitions programs?
  • What are some of the problems with the care continuum between healthcare settings?
  • Are there any care transition projects currently being conducted?

"In summary the continuum of care is seeing and emergence of transitional care from hospital to home that is not only resulting in reduced health care costs but is saving lives. Hospitals can't do it alone. It also requires acceptance and participation of the patient, the involvement of many post discharge care providers and a buy in of the insurance industry to recognize, support and fund the cost saving benefits from transitional care".

Click here to continue reading about transitional care.

Readmittance to Hospitals is Costing Billions

by Sarah Gantz, Baltimore Business Journal

U.S. hospitals spent $41.3 billion treating patients who returned to the hospital within a month of being sent home, often for conditions that could be better managed by a primary care doctor.

Chronic health conditions, such as diabetes, and behavioral health issues, including mood disorders and substance abuse, are among the top reasons patients return to the hospital within 30 days, according to a report by the Agency for Healthcare Research and Quality (AHRQ), which is part of the federal health department.

Readmissions - specifically when patients are readmitted within 30 days - are a quality metric hospitals are watching closely. Often, patients' returning shortly after they are discharged is a sign that they did not get the care they needed on their first visit. Medicare penalizes hospitals if too many of their patients are readmitted within 30 days.

Understanding what medical conditions are bringing patients back to hospitals within 30 days can help hospitals lower their readmission rates and save hospitals money.

Click here to learn more about hospital readmittance.

Seniors on the Move

Currently, there are about 8.4 million senior citizens who depend on others for their transportation. Shortly, the number of older drivers will more than double, making the issue of senior transportation even more critical. In fact, according to the Administration on Aging, by the year 2030 the number of drivers over age 85 will be 4-5 times what it is today. Because America's roads and automobiles are not designed for the existing elderly population-and because the skills and abilities associated with driving tend to diminish with age-viable alternate forms of transportation for the elderly will continue to be an important issue for years to come.


Right at Home of Wake County has "Seniors on the Move", a transportation shuttle service to accommodate the needs of our seniors. A valuable service for individuals living at home or in a facility without the ability to transport themselves. Also we can even provide errand service for those who can't make the trip. Passengers must be ambulatory and able to get in and out of the vehicle with minimal assistance, although we can provide a wheelchair for those who need that assistance.

What can our shuttle service do for you?

caregiver with client.

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