Ready-Set-Go Home: Quality Transitional Care at Home for Seniors

If you or your loved one has ever been admitted to the hospital, the one thing you probably longed for most was to return to the safety and comfort of your own home. A study from the University of Alberta found that older adults who had been discharged from the hospital were 40 per cent more likely to be readmitted within 30 days of discharge.

Senior Home Care by Angels is committed to helping seniors stay at home where they are most comfortable. Through our Ready-Set-Go Home program, we help seniors recover in familiar surroundings and lower the likelihood of re-admission by providing quality, personalized transitional care at home.

Why Do Re-admissions Among Seniors Occur?

To address the high rate of hospital re-admissions, we must first understand why re-admissions occur. The reasons for re-admission are varied, but often include:

  • Difficulty managing a disease or illness at home
  • Exhaustion due to disrupted sleep and eating schedules while in the hospital
  • Lack of follow-through with discharge instructions
  • Medication issues - not taking appropriately, missing doses, etc.
  • Lack of timely follow-up with medical appointments or lack of follow-through with medical instructions

Regardless of the reason, what's most important is that quality transitional care at home can help reduce the likelihood of being re-admitted.

How Our Ready-Set-Go Home Program Provides Quality Transitional Care at Home

At Senior Home Care by Angels, we address these issues and others by using a three-prong approach to transitional care at home for our clients returning home after a hospital stay:

  1. At the hospital – with Senior Home Care by Angels, we offer peace of mind. If one of our clients is hospitalized, we visit him or her at the hospital upon request. We believe collaboration with the hospital discharge planner is necessary to help ensure success at home. During the hospital visit, we provide our client with a copy of ‘Ready- Set – Go Home’, a discharge planning guide. Specific items in the guide prompt the client to ask pertinent questions about issues that impact readmissions, such as symptoms to report, times and dates of follow up appointments, medications, special dietary needs, home equipment needs, etc. For maximum benefit, this guide should be initiated prior to discharge and used across the care continuum from the hospital to the home and brought to subsequent medical appointments. 
  2. At the client’s home – Our caregivers are the ‘eyes and ears’ in the home.  Our staff and Caregivers have unique insight into why clients don’t follow up with appointments, why they miss medication doses and other actions that can lead to re-admission. We can share this information with the case manager or supervisor so any issues can be addressed. Additionally, many of our caregivers are trained to provide Holistic care at home. This training enables our caregivers to understand the importance of reporting changes in condition promptly so any problems can be addressed in a timely manner.
  3. At our Senior Home Care by Angels office – Behind the scenes, we utilize tools and resources to identify and track clients who are at high risk for re-admission. We can help facilitate medication delivery, equipment, and food delivery services, offer medication and appointment reminders, and accompany clients to appointments.

Call us at 519-653-8185, or click here to contact us to find out more.

We look forward to meeting you and your family and being able to provide the transitional care at home your loved one needs!

Each Senior Home Care by Angels agency is a franchise that is independently owned and operated. The Franchisor, Visiting Homecare International Inc., does not control or manage the day to day business operations of any Senior Home Care by Angels franchised agency.
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