Transitional Care from Hospital to Home: Beyond the ER™ (BETER) Care

One of the common reasons that people reach out to an in-home healthcare provider is due to an urgent need. They or their loved one have had an unexpected health issue arise that causes them to end up in the ER or inpatient care. A heart attack or stroke, a broken leg, cancers, or severe respiratory infections like pneumonia can happen to anyone, of any age, at any time — and recovery can be particularly challenging for older adults.

Suddenly, you may find yourself needing a transitional care plan so that you or your loved one can come home.

Inpatient care is not only expensive, it’s simply not the ideal environment for recovery. Studies have shown that in-home care greatly improves patient outcomes. But you can’t simply be sent home from the hospital with complex care needs and no medical support. That’s why we developed our BEYOND THE ER™ (BETER) Care Package.

How BETER Care Works

BETER Care is designed to assist with transitions from planned or unplanned hospitalizations, ER, or rehab facilities to home or hospice.

Transitioning from a facility or an emergency room visit can have many challenges. There may be changes that need to be made to the home environment, like installing grab bars and ramps or creating a bedroom space on the ground floor of a multi-story home. Even little things like moving every-day use items down to more reachable locations from upper shelves or cabinets can make a huge impact on the success of in-home recovery.

Medical monitoring, medication administration, and physical therapy assistance may also be required in the first few days or weeks of transitioning to home.

There is so much to do and so many variables in how each person will respond and adapt to the necessary changes in their environment and schedule. The BETER Care Package addresses those uncertainties and provides a safety net while we slowly transition individuals to increasing levels of independence, ongoing care, or hospice.

Our tapered 30-day plan, starting with 24/7 care for 1 week and gradually decreasing the hours per day each week for 4 weeks, increases the likelihood of success at home. This plan includes:

• Nursing oversight and support on a weekly basis
• Personal care services
• Assistance with prescribed physical therapy treatments
• Transportation to follow up appointments
• Light housekeeping (laundry and other household chores)
• Cleaning out and restocking the refrigerator if needed
• Coordination of care with your choice of home health or hospice provider