At Hospice of Palm Beach County and Hospice of Broward County, we’ve been caring for patients for over 30 years. As not-for-profit hospices, our philosophy is simple – we do whatever it takes to put patients and families first. We’ve developed a Transition Care program to ensure patients transition into hospice care safely and compassionately.
We Work with Physicians as We Continue Care
Physicians have a deep understanding and history of their patients. We invite physicians to be a part of the hospice care plan. Patients may be able to continue treatments, such as radiation and chemotherapy, if they provide comfort and alleviate symptoms.
We Share Your Goal of a Safe Discharge for Your Patient
Our Transition Care program ensures the coordination and continuity of health care for hospice patients transitioning to their homes after a hospital stay. We take steps to ensure your patient is less likely to be readmitted to the hospital and more likely to safely achieve their symptom management goals.
We Provide Extra Post-Acute Support for New Hospice Patients
We provide that layer of support that newly discharged patients need to follow discharge instructions and manage their condition safely once they arrive home. We provide:
• Education and support for the patient and family
• Assistance and attention in the patient’s home
• Coordination of aftercare appointments and case management
• Communication among the healthcare professionals involved in the transition
Our Follow-up Reduces Unnecessary Hospital Readmissions
Transition Care fills the gap between hospital discharge and a patient’s care in the home. We begin before discharge. We communicate with hospital staff to check on the patient’s status and prepare an individualized care plan, taking into account risk factors that could lead to re-hospitalization or a symptom crisis. Common risk factors for readmission include:
• Not knowing what to do in the event of a symptom crisis
• Not understanding medications and when to take them
• Lack of ability to anticipate and understand symptoms
• Poor understanding of the diagnosis
• Safety risks
• Absence of advance directives
If a patient has any risk for re-hospitalization, we provide an intensive level of support to help them manage safely at home.
After discharge by the hospital, a hospice social worker and nurse provide personal education for the patient, focusing on areas that pose a risk for re-hospitalization.
If there is a symptom crisis after discharge, acute care in one of our hospice inpatient units or hospice contract beds is available. In these cases, we can also offer short-term crisis care in the home until symptoms can be controlled.
We’re There
Whether your patient lives in Palm Beach County or Broward County, Transition Care is available to meet their transition needs. Hospice of Palm Beach County and Hospice of Broward County raise funds year-round to be able to offer this extra support to new hospice patients, regardless of ability to pay.