When a person or dear loved is dealing with advanced illness, terminal disease, or chronic pain, having a medical team on the side of the patient and their family can be so important in improving the level of care and, most importantly, the quality of life. A strong medical team studied in hospice transitional care models will help provide a plan of action, ensuring that the patient have customized care with comfort and concern. An individualized plan provides peace of mind, and ensures the patient and their family spend less time worrying about appropriate care and more time focusing on their life and remaining time together.
Transitional care models work with hospice and other palliative care centers to treat the patient as a complex individual with multiple concerns, focusing on healthcare and physiological problems, like the illness and care plans. Transitional care also focuses on the other facets of care: mental and spiritual needs. Working as a team, specially trained nurses, doctors, social workers, and spiritual counselors act as individual parts to support the patient’s overall care plan. This team of high quality care providers work together to provide constant support to the patient and their family, helping to smooth the transition from hospital to home to hospice and provide key information at a sensitive time.
What are Transitional Care Models?
Transitional care models differ based on the needs of each patient and their individual spiritual, cultural, and healthcare concerns. Individuals who have been diagnosed with extreme medical circumstances and their loved ones must often visit medical facilities—from one hospital to another hospital—in and out of long-term care facilities. Through all this change and with declining health, it’s important for a person going through the care process the patient and families feel comfortable supported by a facility, especially near the end of life.
Transitional care models involve programs set up by organizations to ensure help for patients and families adjusting to the emotional and physical changes that become a part of living with a person and their serious illness Transitional care is designed for patients with illnesses that hinder their quality of life. These patients may have end-of-life needs and continue to receive treatment, but are not yet considered ready for full hospice or home care.
Transitional Care & Its Steps
Transitional care models may not be a first concern when a loved one is preparing for discharge at a medical facility, or when a patient immediately discovers a health concern. However, many hospices and care centers have transitional care workers who focus on the process and base their work on problem solving the needs of each patient and maintaining their individual spiritual and cultural needs as well. When one finds themselves or their loved ones in need of transitional care, many hospices and medical centers will begin a process with transitional care managers to ensure quality care.
Screening Process
The first step in this process is screening. Screeners use a variety of factors (including mental and physical stability and amount of care) to target individuals who have key concerns and match them with a medical care team member. The transitional care staff are trained professionals who will spend time with the individual to best understand their care needs, targeting those who are in transition from hospital to home to hospice and may be at a high risk for negative action.
Building Patient/Staff Relationships
Transitional care models involve staff that act as care managers, whose primary responsibility is to maintain and establish relationships with patients and their families in order to develop trust and a plan of care. Through in-person visits, telephone calls, or email, the transitional care staff can walk the patient and their family along with other healthcare processes, helping to keep in contact with other health care providers. This most important role builds a level of trust and respect between team member, family, and the patient, focusing on building and maintaining health care relationships.
Building strong relationships is key to working with the seriously ill and their families. Transitional care focuses on advocating and communication, both of which are important skills for the seriously ill and their loved ones. Trusting a worker to provide all the information is half of the relationship. A transitional care worker must be able to show that they are fully invested in their patients and their families, so that all health care preferences and personal values are met and respected.
Initial Assessment
The first step in any transitional care system is in initial assessment. A health care professional will meet with the patient and their family to discuss the patient’s needs along with treatment options. This process involves exhaustive questions, which help to identify and address the symptoms head on, noting the patient’s risk factors and symptoms.
Education, Support, and Continuing Care
The next step in most transitional care models is to educate the patient and their families on how to identify these risk factors and avoid them. Caregivers also will discuss how to respond to the illness or its treatments. Transitional care professionals will take the time to explain how a patient must be aware of their health and manage it based on health care plans and medication regimens. The medical team will provide mental and psychological/emotional support outlets for the patient and their family, which can prepare the ill and their caregivers to identify and respond to any symptoms.
Studies show that when families or caretakers know little about providing solutions to symptoms, a patient’s quality of life decreases exponentially. Make sure all the patient’s information is kept in one folder so that it may be shared among a large medical team. The transitional care manager will help provide follow-up appointments and set up continuing care. Transitional care models are designed so that communications breakdowns lessen between levels of care. Working with a team of connected medical professionals provides a net benefit to the patient’s overall quality of life.
Remember…
When focusing on one’s care or that of a loved one, it is important to know everything one can about all the medical history, treatment history, and process. It’s often confusing when and how to ask for help. Hospice Transitional Care Models offer more chance for open communication between all levels of care: from a patient’s family to any doctors and physicians, back to the palliative or hospice care team, which is built to ensure the patient receive the best care possible.
When a person or dear loved is dealing with advanced illness, terminal disease, or chronic pain, it’s difficult to know exactly what to do. Try communicating with a local hospice or palliative care center to build a transitional care team. These people work to treat the patient in a holistic manner, focusing on their specific guidelines and needs while focusing on continuing mental health and physical problems. High quality health care providers will work together with a patient and their families to provide constant support. Knowledge empowers families, and smooth transitions from hospital to home to hospice help keep patients calm, happy, and focusing toward the next stages of their life.
