Nursing homes are not a topic only for those who need support for daily living or elderly, but also anyone who recover from an illness and needs a little bit of support to get back to their independent lifestyle – The lifestyle they had just before getting sick or going through a surgery. This care path is known as Transition Care, as it helps you or your loved one to transit between a hospital and your own home.

Here I cover one of the main questions you may have – When should I consider nursing homes for after hospital care? Here I will also go into details of transition care, general eligibility for transition care, Key benefits of receiving transition care at an aged care facility and some key factors affecting the success of transition care, and more…

Before jumping into some complex questions, let’s define what transition care actually is.

What is Transition Care?

Transitional care is a short-term rehabilitation opportunity specially designed for convalescents.

Depending on the type of illness the patient is recovering from, transitional care usually prepares them to bounce back to their daily activity. During the period you will stay in transitional care, you could receive so many treatments like speech, occupational or physical therapy, in addition to medicines. With the aid of nursing care, you will receive help with activities of daily living, wound care and medication management.

When it is time for you to finally get ‘discharged’ from transitional care, the social workers and occupational therapist will help to arrange everything you will need at home to help continue your recovery. Community nurses are likely to take over the needs of any ongoing nursing and health care assistance.

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Transition care can run for 12 weeks and can take place in;

  • An aged care facility
  • A community care facility
  • At your home (home care), or
  • Combination of an aged care, home and/or community care

Why is Transition Care Programs Important?

Older people seek to enjoy the comfort of their own home; therefore, transition care programs help them to;

  • Avoid requiring longer-term care by rushing back home to take care of themselves.
  • Delay movement to an aged care home for as long as possible.
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What Services Do Transition Care Programs Provide?

The kind of care and support transition care program can provide you or your loved one with are;

  • You will receive your medical treatments and other health services like physiotherapy, podiatry, social work and occupational therapy.
  • You will receive nursing support
  • You will receive personal care

Are You Eligible For Transition Care Program?

To be eligible for transition care, you must get an assessment with an aged care assessment team.

Also, you or your loved one need to;

  • Be a patient in a public or private hospital
  • About to be discharged from the hospital, and
  • The Assessment Team should be convinced that you would benefit from receiving transitional care services for a short period of time

Suppose you are eligible and will receive care in a residential care setting, in most cases. In that case, you will have to enter transition care within 24 hours of being discharged from the hospital.

If you are to receive care in your home, you have up to 48 hours from the time of your discharge from the hospital to receive the care needed. If you are to receive care at home, have in mind that health services are responsible for ensuring safe discharge practices. The local health services should be available and accept your care for the hospital to be confident that the discharging patient will be adequately supported for a period as he/she enters into the home-based transition care program.

Who are The Target Groups For Transition Care Programs?

The people for whom transition care are mainly targeted includes;

  • Older people need further improvement to their physical, cognitive and psychosocial functioning and improved capacity. This transition care will enable them to live independently once the program finishes.
  • Older people with a focus to optimize their functioning while assisting them and their families to make other long-term arrangement for care. For example, until the family find a nursing home for a long-term stay.
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Aged Care vs At-Home Care After Hospitalization – What is The Difference?

After hospitalization, caregivers and loved ones of the elderly are faced with the challenge of what to do next. Considering that there is a likelihood of them (elderly) falling sick again or having an unsupervised fall, they are faced with two options,

  • taking them back to home and take the risk, or
  • transferring them to transition care.

Yes, there are many opinions about both options, especially when you add cultural beliefs, values, and myths to the equation, but each opinion differed in its scope and objective. This had made it a bit hard to draw a conclusion on what is best for elders, let’s say for our moms and dads who are convalescents.

Besides home care, there are different aged care available for the elders, which are provided by different types of organizations (e.g. public, not-for-profit, private…etc.).

Nevertheless, in this section, we will compare aged care vs home care for patients after hospitalization.

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Most people in the western world, such as Australia, generally believe that it is best to place the elderly in a nursing home or other skilled facilities.

However, it will be worthy of note that allowing seniors to recover at home always proves more efficient because of the following reasons if you are from a country with a lack of regulation and monitoring into aged care nursing homes.

  • Quicker recovery

Keeping the seniors at home with access to loved ones and family usually keep them happy and help them recover quickly. Allowing them to stay in their homes offers them more balance, especially psychologically and spiritually.

Your sick elderly may not want to follow a rigid schedule and routine. Some nursing homes may follow a rigid schedule and routine, and this usually does not go well for most elders and seniors. Keeping them at home makes room for more flexibility both for the seniors and those taking care of them. It will also allow for family members and friends to visit at will too.

  • Finance

It costs quite a lot to pay for a room and board at a nursing facility or assisted living centre (if you are self-funded with no government support). In that view, of course, it will be cheaper to receive care at home.

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There are different options that will allow you to provide health care for your senior loved ones at home, if you are financially tight and there is no government support. In this case, you can divide the needs of the elderly loved one, to medical and nursing needs, and everything else. While a health care community nurse and a support worker can provide their services by administering medicine, bathing, and providing the needed therapy, any available family member can help out with every other house chores.

By doing this, you are reducing the money that would have been spent for a nursing home or transitional care. Due to this huge expenditure difference in the home care, nursing home care and hospital care, now you can understand why there is an increasing number of home visiting community nurses these days.

  • Availability of modern medical technology

One of the greatest fear of caregivers in keeping elders at home is the limited access to medical technology and skills. Due to the advancement in age and invention of modern medical technology, seniors can now receive some important and useful therapies at home. For example, Blood Sugar Monitoring for diabetes and blood pressure monitoring…etc.

Tip: We recently discussed the characteristics of a good nursing home for someone with diabetes.

Home care nurses and support workers (carers) perform most procedures like dressing wounds, changing bandages, hygiene, and personal care are performed by home care nurses and support workers (carers). This is made possible by the modern medical equipment and aids (e.g. lipped plates) that are made available.

  • Freedom

Hospitals offer plenty of restrictions. You can’t freely do whatever you wish because there are already laid down rules and guidelines in the hospital. This kind of environment might not be ideal for convalescing seniors, and there will be more comfortable in their own homes.

Being at home helps them receive and visit people at will. They can also create their own meal schedule as per their liking and routine.

As a caregiver, before you make a final decision on what to do with mending a senior under your watch, you might consider including them in the decision-making process. Especially, if they are in a sound cognitive capacity, with no dementia or Alzheimer’s.

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Now let’s talk about the reality of the modern world, especially if you live in a western country (OECD) and are happy to keep emotions aside and would like to achieve the best outcomes for your loved elderly family member.

Key Benefits Of Receiving Transition Care At An Aged Care Facility

Receiving transition care at an aged care facility will make the following services available to you. It just matters a need and a request. The service can be right in front of your loved ones within minutes to hours.

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Top of that, the skillful nurses on-site will decide what is best for the elderly and when the extra support is needed in the best interest of the resident. You can expect that level of attention in an environment such as your own home, where mostly emotions drive decisions over skills and experience.

At a nursing home, your loved one will have the following services promptly.

  • Nursing care
  • Physiotherapy
  • Occupational therapy
  • Dietetics
  • Speech therapy
  • Podiatry
  • Counselling
  • Social work
  • Social activities and some new friends.

You will also receive the following services from a registered nurse.

You will also receive daily personal care services.

  • You will receive assistance with showering and dressing
  • You will receive eating aids
  • You will receive help in managing incontinence
  • Transport to appointments
  • Mobility and communication
  • Dressing or assistance in using dressing aids
  • Any other daily living needs you may have

When Should You Consider Nursing Homes For After Hospital Care?

There is always a mix of feelings accompanying a decision to move your loved ones to a nursing home. There is always a feeling of guilt, anxiety, and grief.

However, it is important that you rise above all those feelings when you notice that your loved ones require a higher level of care.

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Many caregivers feel guilty and conscious of the heartache when they are considering moving their loved ones into a nursing home. They always have it at the back of their mind that it is their full responsibility to cater for their loved ones. Considering nursing homes usually make them feel as though they are shying away from their duties. Some even feel that those homes will not provide adequate care for their loved ones too.

Nevertheless, when you notice that the senior in your care needs higher care like nursing care, you should consider a few things.

Some of these includes

  • If you are the caregiver, ask the following questions about yourself.

Are you finding it difficult to provide complete care for your loved one?

Do you feel emotionally drained or exhausted?

Do you feel the person you are catering for needs professional supervision?

Do you have enough skills, strengths and experience in caring for the elderly?

  • Other indicators to suggest you might struggle to care for your loved ones at home includes:

Do you usually hurt your back when trying to lift your loved one?

Has the condition of the senior progressed to the point that you now fear for their safety, especially while you are not around?

Have there been situations where your loved one wandered or got lost in cases of a mental problem (e.g. dementia)?

Does catering for the senior make you neglect your other essential duties to the point of creating problems for yourself or your family?

Are you experiencing burnout?

Do you feel a decline or reduction in your own health?

Do you feel your personal relationships (e.g. with your spouse, partner or kids) are suffering as a result of giving all your tie and attention to the senior?

Are you starting to neglect the need of other loved ones?

Do you feel it will be cheaper to pay for a nursing home and avoid any costly expenses of keeping the senior at home?

  • Other definitive indications that you should strongly consider a nursing home for your loved one include;

Is the senior finding it hard to eat, and you don’t have the skills and resources to manage that problem?

Is the senior constantly getting bruises?

The loved one cannot bathe, dress and do their own laundry, and you are not available to help and support either?

The elderly or their carers consistently taking wrong medication and/or inaccurate dosage?

You or the elderly loved one have no alternative plan in place of what to do in case of an emergency

The older person or their cares do not drive or have another efficient means of transportation.

Does the senior feel isolated from family and friends in their present environment?

If your answers to most of the above questions happen to be a concern to you, then you should consider taking your loved one to a nursing home. No matter how hard it may seem or how bad you feel about that, taking them to a nursing home might be the best alternative for them.

You shouldn’t completely give up your own life because you are trying to cater and care for your loved one. After all, nursing homes are not as bad as they sound, so consider it a helpful option for both you and your loved one to live happier and longer.

Now, let’s get back to transitional care…

Factors Affecting The Success Of Transition Care

Of all the initiatives and support available through transition care programs, no single one has been able to address the needs in their entirety consistently. While most of the interventions and support receive positive outcomes, some of the reports also show poor health outcomes accompanied by a patient and their family dissatisfaction.

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Also, the success of transition care differs across different geographical areas and populations. A strategy might work effectively well in a location and fail to work in the next location. As such, there can try and see element can be involved.

To determine the success of transition care, the context of implementation should be greatly considered.

Some of the factors affecting the success of transition care include:

  • The organization’s culture should be considered when coming up with solutions for the problems your loved one has.

There is a need for interventions to be integrated within a comprehensive and client-centred approach. Appropriate financing mechanisms should also support it. These reliable information transfer systems will facilitate sharing, clinician support and culturally sensitive strategies to address patient/client and their family’s health literacy and patient engagement.

  • Other factors contributing to the success include the potential location of health services, patient registers, shared decision support systems across, the development of clinical pathways for specific conditions and formalized relationships between health professionals or health services in different sectors and jurisdictions.
  • There might also be a need for the introduction of new roles owing to these recent interventions. Although this might be disruptive and inconvenient for the existing staff, it will make implementation easier.

This will even be better within a supportive culture that takes into account aspects such as staff satisfaction and development, strategic and systemic management of the skill mix change. This is coordinated by the senior management, and the development of a methodology for change that is shaped by employee participation.

Having known this, it is important to note that there is no definite approach to making transition care successful.

Every group or home involved in transition care can choose to adopt the WHO member state strategies.

Some of their strategies include;

1. The nursing home share tools and also develop governance arrangements

  • This can be carried out by sharing approaches to governance through different organizations and sectors. By doing this, a network of governance is created, and this will in turn support and improve safer transition care.
  • Rather than relying solely on the oral method of communication, which involves passing information from one health care practitioner to the next about a certain patient, the electronic mode of information and documentation could be adopted. This will make the transfer of information easy and stress-free.
  • It is necessary to standardize every important process like appointments, medical records, test results, information flow and communication.
  • Nursing homes should always ensure that key tasks are performed in a standardized manner. This can be achieved using a checklist.
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2. Nursing homes use the systems approach

  • Owing to the fact that no single intervention has been found to address all the solutions, the nursing home can combine evidence-based intervention to support safer and smoother transitions.

Nursing homes can achieve this by using a systems approach that includes three aspects for all patients and residents.

  • The nursing team should consist of residents and their carers too
  • The staff should ensure that there is the timely transfer of accurate clinical and social information between settings
  • Medication reconciliation is also mandatory

3. The nursing home must prioritize patients at more risk of safety incidents

The nursing home can achieve this by

  • Employing tools that will help to identify transitions at high risk of safety incidents.
  • Engage in research that will help inform the nursing management of the improvements in transition care, especially for the elderly, those with complex conditions, and patients with low socioeconomic status.

4. Nursing should continuously improve relationships and communications.

Nursing homes can achieve this by

  • By bringing to the attention of their strategies to improve communication between patients (clients) and health care providers and among organizations.
  • Make available the checklists and written instructions about the transition for patients, family members, and carers.
  • By ensuring that they are using the standardized terminology between primary and secondary care.


Suppose you have an older person who needs transition care. In that case, you can use any of the transition care options available to you.

During the transition, from hospital to own home, if you are eligible and need to transfer your loved one to an aged care facility or nursing home, feel free to do that. You don’t need to feel bad about getting extra care. Those homes are made available to provide extra services and ease people the stress of singlehandedly taking care of their loved ones.

You may sometimes feel that providing care at home is the best option for caring for your family, but check when you start burning out. (refer to the checklist above). Remember, your ultimate goal should be to provide the best care to your loved one in need as well as to you and your immediate family, for each member have the best out of their life – healthy, happy and long life!