Published on June 04, 2018

caregiver helping man use a walker

Taking the Worries Out of Care Transitions

Transitions are always challenging. Whether from the hospital to home, or from home to a long-term care center, such transitions can be filled with worry and fear of the unknown.

When families reach out to professionals who know the “drill” and can help remove some of the mystery, it can make a huge difference. Compassionate care, regardless of location, can help dissipate the worry not just for the person who is sick, but for their family as well.

“There are different types of these transitions, such as a change from hospital to home, the transfer from at-home care to hospice care or a change from care at home to a long-term care facility,” said Jill Nuebel, RN, MSN, Agency Manager for Avera@Home. “In many cases, it helps to have conversations about the person’s wishes before the changes come along, but that’s not always possible. No matter what sort of change is occurring, there are resources available that can make it smoother and as comfortable as possible.”

Hospital to Home

Nuebel said professional help at each step in a transition is a normal – and extremely helpful – aspect of the process.

“All transitions begin with a physician’s orders, and then a variety of nurses, social workers and patient-care coordinators will spend time with the patient and family to go through things so it all makes sense,” she said. “The process looks at a number of factors, including the patient’s medication and therapy plans. They also will consider who in the family will be helping care for them at home as well as the home itself. Patient safety is priority.”

Patients and families also have help with insurance and financial questions during the process to set up at-home care. Social workers consider all scenarios and help the family to approach the next step in the patients recovery carefully, so the outcome can be the best possible.

“The discussion is extensive, because there are a number of regulations and requirements needed in some cases,” said Nuebel, who cited the example of stairs in a home. “We often provide a lot of guidance and answer a lot of questions, but it’s really about the patient. They are the final decision-maker on almost everything, in compliance with the physician’s recommendations.”

Hospice and Long-Term Care Needs

Hospice care is specialized, and Nuebel said that conversation with the family is one where learning is commonplace.

“It’s important for patients and family to understand the differences between traditional at-home care and hospice care. If the patient and his or her physician feel hospice is the best next step, we take time to spell out what it’ll mean with the family,” she said. “We can visit the home and make sure the patient and family have all they need.”

Whether a person needs home hospice care, or care in a hospice facility, such as Avera Majestic Bluffs Hospice House or Dougherty Hospice House, depends on their needs. For example, hospice facilities offer around-the-clock care.

“We consider the needs of the patient in all cases, and help patients and families understand the role of hospice in a patient’s wellbeing,” she said. “In most cases, hospice-house stays are privately paid-for, while some programs can help people to cover the cost.”

When people are considering a loved one’s move to a long-term care facility, professionals like Nuebel can be helpful in considering options, weighing costs and waiting-list issues and gaining the insight needed to make best choices for all parties. Nuebel said the Avera@Home teams are well-versed with the seemingly daunting process of applying for aid or seeking local resources for those in need.

“We respect each patient’s wishes and provide moral support as we guide them through the process,” she said. “We can help answer a lot of questions and help bolster confidence, because it can be a very overwhelming process.”

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Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian values.