Transitional Care

What is Transitional Care?

Transitional care bridges the gap between hospital and home. It ensures that when someone is discharged from a hospital or rehabilitation setting, they have the support, information, and resources needed to recover safely and confidently at home.

For many older adults and individuals with chronic conditions, this period can be confusing or overwhelming - with new medications, follow-up appointments, and care routines to manage. That’s where Hospital 2 Home comes in.

Our team of licensed social workers, case managers, and respite coaches guides clients and caregivers through every step of the transition process. We coordinate with medical providers, address barriers to care, and connect families to community programs and long-term supports that promote stability and independence.

An elderly woman using a walker, with assistance from a caregiver, walking outdoors near a house with greenery.
About Hospital 2 Home
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Benefits of Transitional Care

Research shows older adults who receive structured transitional care support are around 25-40% less likely to be readmitted to hospital within 30 days, thanks to improved coordination and follow-up.

Hospital 2 Home helps clients and caregivers achieve:

  • Better health outcomes and greater medical stability

  • Reduced caregiver burden

  • Improved patient engagement

  • Easier access to long-term care resources

  • Stronger coordination across care settings

  • Prolonged independence at home

Learn More
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“With tears in my eyes I want to thank you very much for helping me.Without your help I could not have made it. May God bless you for helping people to live.”

Terri S.