Meet Catherine. Catherine has had knee replacement surgery and also has diabetes and mild dementia.
Transitional Care
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Transitional care at Stonerise.
Healthcare transitions. You’ve probably already experienced one, either with a loved one or while managing your own health. It was likely a stressful, confusing or cold experience with poor communication or support—or all of the above, leaving you uncertain of what to do. Fortunately, it does not have to be this way.
We want care transitions—whether it is after a hospital stay or coordinating with multiple specialty physicians—to be less uncertain, more human and more loving.
At Stonerise, we define transitional care as warmly and smoothly transitioning patients from one care provider or level of care to another.
The complexity of care today.
Healthcare is complex. Instead of acting like one stop on the healthcare journey, Stonerise helps patients transition from one care provider or level of care to another, and we help connect patients with other providers and community resources.
Healthcare System Complexity
See a possible example of a patient transitional care journey
A Stonerise liaison who supports Catherine’s local hospital helps Catherine find a short-term stay at one of our transitional care centers. Stonerise quickly helps verify her insurance coverage.
Through 14 days of physical therapy, specialty physician coordination, cognitive assessments and nutritional coaching, Stonerise is able to get Catherine ready to go home.
The Stonerise center care team collaborates closely with our Stonerise Home Health team to create a seamless transition to ensure Catherine’s care plan continues at home and care is focused on achieving her particular goals.
Today, Catherine is back to her life and daily routine and has not needed another hospital stay.
Extra support during transitions is especially important for the patients we serve: those who are aging or managing multiple conditions, as well as their family caregivers. These patients typically receive care from many providers and move frequently between healthcare settings. They are also at very high risk for hospital stays.
That is why we embed transitional care into everything we do, whether in our transitional care centers or at a patient’s home. We are also committed to helping patients connect with and navigate the services or providers needed outside The Stonerise Network—for example, with assisted living centers or hospitals. And we fully engage with and support each patient’s primary care and specialty care physicians’ treatment plans.
Often, nursing homes are intended to be the last stop in a person’s care journey. That is not our model or our vision for transitional care at Stonerise. Our care centers are called “transitional care centers” because we offer short-term stays to help patients get as healthy as possible so they can return home and get back to life, hopefully with the support of Stonerise Home Health. We also offer long-term stays for patients who need longer term care.
Our breadth of services is designed to support patients who are leaving a hospital stay or are at high risk of needing a future hospital stay. In West Virginia, we are the only provider that owns and delivers short- and long-term skilled nursing stays at our transitional care centers, in addition to full-scale home health and therapy service lines. We offer these different services so we can stay with patients longer and give them the best health outcomes possible.
Transitional care brings many benefits to patients, families, hospitals and physicians:
- Clearly tells patients what to expect, what to do and how to navigate through the unknowns.
- Reduces the gaps in communication and support that could lead to future hospital stays.
- Lowers stress for patients, their families and their caregivers.
- Helps patients focus on getting back to health and back to life.
- Supports patients as they experience health transitions throughout their lives.
For hospitals and physicians, transitional care brings these benefits:
- Increases communication about a patient’s progress and struggles.
- Offers peace of mind that patients are discharged with a partner (Stonerise) that keeps them engaged, gets them home and keeps them home.
- Decreases patient readmissions and avoidable hospitalizations.
- Gives one single point of contact for referrals across all Stonerise service offerings.