Transitioning From Hospital or Rehab Care Should Not Add Challenges to Life

TFAD Recommendation #11

Hospital Transitional Care Practices

TFAD wants to ensure high quality hospital-to-community (i.e. home and long-term care) care transition programs are available to -people living with dementia and their caregivers, with key elements including care/discharge planning, care management and associated tools, information on community resources, wrap-around services, periodic follow-up check-ins and assessments, strategies for living well with dementia and dementia self-management resources. Humboldt county has Community Paramedics Program for hospital to home transitions.

To explore new innovations and expand existing support efforts, TFAD encourages the Nevada Department of Health and Human Services to investigate federal funding opportunities through the Centers for Medicare and Medicaid Services and the CMS Innovations programs. Wide-spread use of care transition programs may be explored by seeking and establishing key partnerships with Nevada Healthcare providers and systems.

Efforts should be taken to mobilize continuing education programs designed to build healthcare providers’ understanding of the importance of care transition planning and skills in convening interprofessional teams to counsel and support patients at the time of discharge.

Hospital-to-Community care transition programs should emphasize the essential role of family and caregivers and should