Transitional Care Program

Portrait of three smiling doctors in the hospital Returning home from the hospital can be a tough transition for both the patient and their family. After having skilled hospital care, it can be a difficult transition to return home without that same care. The recovery time outside of the hospital can be slower without expert care. Family caregiver support offers resources, counsel, and supportive social services for family members and friends caring for their elderly loved ones at home. This hospital-to-home service provides consultation and services to bridge the gap between a hospital discharge and a strong recovery.

This home care assistance program is offered for a short-term time period, usually for a length of 4-6 weeks. A social worker will first visit the patient in the hospital while they are in the process of getting discharged. Once discharged, the patent may be discharged to their home or to a skilled nursing facility (SNF). The transitional care specialist will visit the patient at home or in the SNF within 3 days of discharge. They will make sure that the patient has transportation to follow-up doctor's appointments, an organized plan to take medications, and will communicate with their nurses and doctors. They will teach them how to take care of themselves after being discharged from the hospital or rehabilitation facility. This senior care service is non-medical and allows patients to be on their own. Social workers will only visit the patient a few times during that 4-6 week span. This program is developed to decrease the number of patient hospital readmissions.

This social service is a part of the Affordable Care Act and helps control costs of the services. The service is specifically funded by the City of San Francisco (San Francisco Office on Aging, Department of Aging and Adult Services and by the Center for Medicare Services. Patients must live in San Francisco, be over the age of 60, have stable housing, and have Medicare as the primary health insurance provider.

If you know someone who may need and qualify for the service, call Self-Help for the Elderly to request information on the Transitional Care Program.