Full Definition

Transitional care programs occupy the space between acute hospitalization and return to community living. They may be provided in a Transitional Care Unit (TCU) within a skilled nursing facility, at home through enhanced home health programs, or through hospital-based care management programs. The defining feature is an explicit readmission prevention focus.

Clinically, transitional care emphasizes medication reconciliation (ensuring the patient and family understand the post-discharge medication regimen), self-care education, scheduling of follow-up appointments before discharge, and post-discharge check-in calls or visits. Research shows that structured transitional care programs significantly reduce 30-day hospital readmissions.

The Medicare BFCC-QIO (Livanta in Texas) monitors readmission rates and works with hospitals and post-acute providers to improve care transitions. Families can ask the hospital discharge planner specifically what transitional care support the hospital is coordinating.