Transitional Care
Transitional care is an essential link in the healing journey and refers to coordinated, short-term healthcare support provided to individuals as they move from one care setting to another—most commonly from hospital to home, or from acute treatment to long-term or rehabilitative care. It focuses on restoring confidence, mobility, and independence, while helping patients and their families adapt to new routines after illness, surgery, or prolonged hospitalization. These transition periods are often marked by vulnerability, confusion, and increased risk of complications, especially for older adults and those with complex medical needs. This compassionate, well-coordinated approach not only reduces the chances of readmission but also enhances the overall quality of life —helping patients heal with dignity, care, and confidence.
At Age Care Foundation, transitional care is designed to ensure that this critical phase is safe, supported, and seamless, preventing avoidable readmissions and helping individuals regain stability, confidence, and independence. We recognise that discharge from a hospital does not mean recovery is complete.
Many patients require continued medical supervision, nursing care, rehabilitation, medication management, and emotional support during the weeks that follow.
Post-Hospital Discharge Planning
Coordination with hospital teams to ensure smooth discharge, clarity on treatment plans, medications, follow-up care, and warning signs.
Medical Monitoring and Follow-Up
Regular medical reviews, monitoring of recovery, management of co-existing conditions, and timely intervention to prevent complications.
Skilled Nursing Care
Support for wound care, catheter and tube care, injections, medication administration, pain management, and vital monitoring.
Medication Management and Education
Review of prescriptions, prevention of medication errors, adherence support, and education for patients and caregivers.
Rehabilitation and Functional Recovery
Physiotherapy and mobility support to rebuild strength, prevent falls, and restore independence after illness, surgery, or prolonged hospitalisation.
Nutrition and Wellness Support
Dietary guidance tailored to recovery needs, chronic conditions, and age-related requirements.
Home-Based Transitional Care
Transitional care services provided in the comfort of the patient’s home, reducing stress and supporting faster, safer recovery.
Emotional and Caregiver Support
Counselling, reassurance, and training for families to help them confidently manage care during the transition period.
Integration with Geriatric and Palliative Care
For elderly patients and those with serious illnesses, transitional care is seamlessly integrated with geriatric and palliative care services to ensure continuity, comfort, and dignity.
A Bridge to Safer Recovery
*At Age Care Foundation, transitional care is more than a service—it is a bridge between illness and recovery, between hospital and home. By providing structured support during this crucial phase, we help individuals heal safely, reduce avoidable hospital readmissions, and empower families with confidence and clarity.
Because recovery does not end at discharge—it begins there, with the right care, at the right time, in the right place.
We've Got Answers
Transitional Care is short-term, coordinated healthcare support provided when a patient moves from one care setting to another—most commonly from hospital to home. It ensures continuity of care during recovery and reduces the risk of complications and hospital readmissions.
Transitional care is especially helpful for: • Older adults after hospital discharge • Patients recovering from surgery, serious illness, or injury • Individuals with multiple medical conditions • Patients who need nursing, rehabilitation, or medical monitoring at home • Families who require guidance in managing post-discharge care
The period immediately after hospital discharge is often a vulnerable time. Transitional care helps: • Prevent avoidable complications and readmissions • Ensure medications are taken correctly • Support recovery and rehabilitation • Provide reassurance and clarity to patients and families
Transitional care is: • Time-bound and goal-oriented • Focused on recovery and stabilisation after acute care • Closely coordinated with hospital discharge plans • Designed to transition patients safely to long-term care or independence
Sneha Sandhya Age Care Foundation provides: • Post-hospital discharge planning and coordination • Medical monitoring and follow-up • Skilled nursing care • Medication review and management • Physiotherapy and rehabilitation support • Nutrition and wellness guidance • Emotional and caregiver support • Home-based transitional care services
Yes. Most transitional care services can be delivered at home, allowing patients to recover in a familiar environment while receiving professional medical and nursing support.
Transitional care is typically provided for a short, defined period, depending on the patient’s condition and recovery needs. The duration is individualised and reviewed regularly.
Care is delivered by a multidisciplinary team, which may include doctors, nurses, physiotherapists, counsellors, and trained caregivers, working together to support recovery.
Families are actively involved and supported through: • Clear guidance on care routines and medications • Training in basic caregiving tasks • Education on warning signs and follow-up needs • Emotional reassurance and counselling
Yes. By ensuring proper follow-up, medication management, rehabilitation, and early identification of complications, transitional care significantly reduces the risk of unnecessary hospital readmissions.
Yes. Transitional care at Sneha Sandhya can be seamlessly integrated with geriatric care for older adults and palliative care for patients with serious or life-limiting illnesses, ensuring continuity and comfort.
Families should consider transitional care when: • A patient is being discharged from hospital • Recovery requires continued medical or nursing support • There are concerns about managing care at home • The patient is elderly or medically complex Early planning leads to smoother transitions and better outcomes.
The goal is to ensure a safe, supported, and confident transition from hospital to home—promoting recovery, preventing complications, and empowering patients and families.