Transitional Care
Coming home after a hospital stay, surgery, or rehabilitation can feel uncertain. AccuCare provides nurse-led transitional care in St. Louis to help older adults return home with a plan that reflects their discharge instructions, recovery needs, and daily routine.
From preparing the home and arranging caregiver support to helping families stay informed, we work to make the hospital-to-home transition feel safer and more manageable. A nurse is involved from the first conversation, and care can grow or step back as your loved one’s needs change.
Approach to Hospital-to-Home Support
Our transitional care for seniors is built around what their discharge team recommends, with a nurse involved from day one. Care plans are developed by Amanda, RN, BSN, and Tina, LPN, then reviewed weekly by the team to help ensure care continues to reflect your loved one’s changing needs.
After Surgery
Nurses on our team build a personalized post-surgery care plan around your loved one's discharge instructions and specific recovery needs, so care at home reflects what their surgical team has recommended. Before your loved one returns home, we complete a home safety assessment so the space is ready for a safe, comfortable recovery.
After Rehabilitation
Whether your loved one is coming home following a stroke, a heart attack, or another significant health event, our team builds a plan around the recovery goals set during rehab, and we can advise on home modifications that support safety and independence.
What Transitional Care Can Include
Every return home is different. Depending on your loved one’s plan and needs, AccuCare can help with preparing for the return home, personal care and mobility support, meal preparation, medication reminders or support from licensed nursing staff when appropriate, transportation or errands, and communication with family members.
We begin with a nurse-led assessment so the plan reflects your loved one’s discharge instructions, home environment, and goals for recovery.
Keeping Your Family Informed
Recovery involves a lot of moving parts. Our caregivers stay closely connected with our nursing team throughout, and your family is kept informed of how your loved one is doing at every step.
FAQ's
Does transition care require a physician's order? No. AccuCare is a private pay service, which means families can start without a referral or physician's order.
How soon can care begin after discharge? We work as quickly as possible to put a plan in place, often before your loved one comes home. See how our care process works or call us to talk through timing based on your situation.
How does AccuCare coordinate care after a hospital or rehabilitation stay? A nurse helps build the care plan around available discharge instructions and your family’s needs. For families who want ongoing, direct coordination with medical providers, our Nurse Care Management program provides that level of dedicated oversight.
What if my loved one needs ongoing support after the transition period? Many families continue with additional care as needs change, from respite or companionship care to Nurse Care Management for more complex situations. A nurse stays involved throughout.
Care That Grows With Your Family
Transitional care is often the beginning of a longer relationship, not a one-time service. As your loved one's needs change after recovery, we adjust with them, whether that means stepping back once they're steady or layering in more support over time. A nurse is present and involved at every stage. We grow with you.
Whenever You Are Ready To Talk, We Are Here
Call us at (314) 692-0020 or request information to learn how our nurse-led team can support your loved one's recovery in St. Louis. Want to know what getting started looks like? See how our care process works.
