Special Needs Plan: Care Transitions

What is a care transition?

A care transition is any time you change the location of where your healthcare needs are being met. A care transition could be:

  • Being admitted to the Hospital or Skilled Nursing Facility from home
  • Being discharged from the Hospital to a Skilled Nursing Facility
  • Being discharged from the Hospital to another care facility
  • Being discharged from the Hospital back to home with or without Home Health

All of these moves involve “transitioning” your receipt of healthcare services from one care setting to another.

What can I do to prepare for a care transition?

If you know you will be going in the hospital make sure you understand:

  • Where you will be admitted and what needs to be done before you are admitted
  • What medicines you will be able to take or not take before being admitted and while you remain in the hospital
  • Whether you will be going home or need more care in another facility when discharged

What can I do during a care transition?

When you are being discharged from a Hospital or any other facility, make certain you:

  • Read and understand your discharge instructions.
  • Know where you will get care after you are discharged. If you need to receive care at a Skilled Nursing Facility, find out your choices.
  • Make sure you understand what things you can and cannot do and that you plan for needed help at home after discharge.
  • Ask if you will need any special equipment after going home and whether any care providers will be coming to your house to help you.
  • Ask about your health condition and what you can do to help yourself get better.
  • Ask about problems you need to watch for and what to do about them. Find out who to call if you have any questions or problems.
  • Make sure to get names and phone numbers of all the doctors who treated you while in the facility.
  • Understand all the medicines you will be taking when you go home. Some of them may have changed or new ones added.
  • You and your family or caregiver need to make sure you know how to change bandages, if needed.

What can I do after a care transition?

Once you have returned home, make certain you do the following:

  • Fill all your prescriptions.
  • Make certain all of your home assistance (if ordered) has arrived.
  • Call your Primary Care Physician (PCP) and make an appointment to be seen within 7 days of going home. Make sure you take all your medicines with you to your follow-up appointment so your doctor can have a record of any changes.
  • Call your specialists and make your follow-up appointments (if needed). Make sure you take all your medicines with you so your specialist can have a correct list.

Who can I call if I need any assistance?

Any questions about your health and your discharge instructions should be directed to the doctors and nurses who are caring for you in the hospital. They should tell you everything so you completely understand what you need to do when you go home. Make sure to get your questions answered before you leave.

After you go home, any health questions should be directed to your Primary Care Physician or Specialist.

If you have any questions about care transitions or need help, our Case and Disease Management staff are available to help you. You can reach the Case and Disease Management Department Monday-Friday from 8am EST to 4pm EST by calling 1-888-211-9913. TTY/TDD users call 1-800-955-8771.

Below is a link to a Medicare website. This link lets you print a checklist to take with you when you are admitted and is very helpful in remembering all the information you should have before going home.

Medicare Discharge Planning Checklist

Last updated 10/01/2023