Transitional Care

What is transitional care?

A visit to the emergency room, admission to the hospital, or a stay in a physical rehabilitation or nursing facility can be a stressful and confusing time for anyone.

However, older adults in particular often have special concerns when facing transition to or from a medical facility or from one medical facility to another.

Patients and families frequently have questions such as:

• Were my medications changed? Am I supposed to take the medication I was prescribed before I was hospitalized?

• Does my primary care doctor know what my specialist is advising? Are they in agreement about my care?

• Am I making progress?

• Can I manage safely when I return home? What services and supports will I need?

The U-M Geriatrics Center Transitional Care Clinic provides assistance to older adults and caregivers facing these concerns. The Transitional Care Clinic provides care for patients with multiple medical problems or who are in need of short- or long-term nursing home or rehabilitation placement to prevent rehospitalization. Medical care and social work support is provided for the patient and the family.
Who should consider the U-M Geriatrics Center Transitional Care Clinic?

Patients who have had sudden hospitalizations, physical rehabilitation facility stays, or emergency room visits
that require urgent outpatient follow-up should consider the Transitional Care Clinic. This may include:

• Patients who have complex medical concerns

• Patients and families who are in need of assistance to help the patient maintain independence

• Patients and families who need assistance understanding the complexities of their health care management

• Patients who are seeing a specialist but do not have a primary care physician

How we can help

The Transitional Care Clinic offers services from a team of experts including physicians, nurses, social workers and pharmacists. Services may include:

• Reviewing of medical status with a geriatric physician

• Assisting patients in managing and obtaining medications

• Referring patients and/or caregivers to in-home and other community services

• Assisting in long-term care planning

• Evaluating patients' conditions by clinic team members to ensure satisfactory progress

• Providing education and assistance to family members and caregivers
The U-M Geriatrics Center Transitional Care Clinic focuses on prompt, professional and personalized follow-up services for seniors.

Contact the Geriatrics Center Transitonal Care Clinic at (734) 764-6831.