The Hospital-to-Home Transitions (Door-through-Door) program provides critical support to seniors who are, or have recently been, hospitalized. The program helps to ensure appropriate care and resources are available post-discharge -- enabling the greatest opportunity for a full, safe recovery.

When a patient is discharged from a hospital stay, their focus needs to be on healing, without the worry of figuring out how to overcome all the other challenges an illness, surgery, or accident might initiate.

The Hospital-to-Home Transitions program helps ensure that medical care plans and social support systems are in place so that clients can safely return home and focus on that healing. Our program also aims to help break the cycle of repeated hospitalizations by ensuring that needed resources and support are available before, during, and after a hospitalization. Whether that means having access to a walker or bedside commode, having a home caregiver right away, having transportation to a doctor or physical therapy appointment, or having prepared food at home during recovery -- we help to make sure that critical needs are met so that stress is reduced, and re-admission risk is minimized.

Our Hospital-to-Home Transitions Coordinator will work directly with the senior and/or their family members, as well as the hospital Discharge Planners and Case Managers, to understand each unique health and home situation, and to identify risks and needs. By educating family members about their rights, and what post-discharge services they may need to ask about, we are often able to mitigate potential challenges before they occur. In order to prevent additional injuries, our Coordinator will often schedule a home visit to look for, and address, fall risks or other safety risks in the home. Our Coordinator has connections with over 2,000 local resources that they can call upon to help with most any situation, and we have connections with all of the local Fallbrook-area skilled nursing and rehabilitation facilities, board and care, and assisted living facilities, if any of them should be needed.  Our relationships with local-area hospitals and other organizations help us to work together for the best possible health outcomes for our seniors.

Our Hospital-to-Home Transitions Coordinator works closely with the North County Fire Protection District and other first responder organizations to ensure that we engage as quickly as possible with a potential Hospital-to-Home Transitions client. If the senior is taken to a nearby hospital, or if there are needs identified in a senior’s home care, the Fire Department personnel will provide a referral, upon consent, to our program. Once we receive that referral, we reach out to the hospital to get an update on the patient’s status, we speak to the patient or their family, and we begin our work to connect the senior with the appropriate resources that they may need.  Sometimes, these referrals come from caring neighbors or friends. During this fragile time after a hospitalization, we are here to help and are only a phone call away.