Transitional Care
Transitional Home Care After Hospital, Surgery, or Rehab
Discharge home with a professional caregiver in place — so your loved one's first 30 days back home don't end in an emergency-room return.
Discharge day comes faster than you expected. The hospital hands you a stack of instructions and a follow-up appointment, and your loved one is home alone by 4 p.m. The first week back is when the falls happen, the medications get missed, and the readmissions start. Transitional care is the difference between a safe recovery and another hospital stay.
Why families choose Resource One for Transitional Care
Same-week start — most transitional care assignments begin the day of discharge or the day after, often arranged from the hospital before discharge
Coverage tapers down as recovery progresses — you can step down from full-day support to a few hours weekly without changing agencies
Caregivers experienced with the non-medical side of post-operative recovery, post-stroke discharge, fall recovery, and post-rehab transitions
Coordination with your home-health agency (separate medical service) and your surgeon's office
Helps reduce readmission risk — the leading causes of readmits in older adults are missed medications and falls in the first 30 days. A non-medical caregiver in the home reminds, observes, and escalates concerns to your home-health nurse before they become emergencies
Flexible payment — private pay, LTC insurance, VA Community Care, and TennCare CHOICES bridge hours where applicable
What we provide
- ✓Help getting safely home from the hospital or rehab — riding home, navigating stairs, managing the first night
- ✓Medication reminders — helping the family stay on top of a complex post-discharge schedule (we remind and observe; we do not administer medications)
- ✓Mobility assistance, transfers, and fall prevention during the high-risk recovery period
- ✓Help following non-medical aftercare instructions (positioning, ice and elevation), and noticing changes to a wound or incision so the home-health nurse or surgeon's office can be called
- ✓Personal care (bathing, dressing) when post-surgical movement is limited
- ✓Encouragement with meals, hydration, and the recovery routine the discharge plan asks for
- ✓Transportation to follow-up appointments, physical therapy, and pharmacy
- ✓Coordination with your home-health nurse, physical therapist, and surgeon's office — they handle the medical work, we handle the everyday support
- ✓Flexible scheduling — full-day coverage tapering down as recovery progresses
Who qualifies
Adults discharging from a hospital, surgical center, rehab facility, or skilled nursing stay who need short-term help at home — typically 2 to 12 weeks. Common reasons include orthopedic surgery (hip, knee, shoulder), cardiac procedures, abdominal surgery, recovery from a fall, post-stroke discharge, and managing the first weeks of a new chronic-illness diagnosis.
How to start
Call our Memphis office at (901) 751-7466 or Jackson at (731) 554-0841 — even from the hospital before discharge.
We can complete a phone assessment within hours and have a caregiver in place by discharge day or the day after.
Coverage starts at the level of support you need (often 8 to 12 hours per day) and tapers down as recovery progresses.
Common questions about Transitional Care
What's the difference between transitional care and home health care?
Home health care is short-term medical care after a hospital stay — skilled nursing visits, physical therapy, occupational therapy — covered by Medicare for limited periods. Transitional home care is non-medical personal support: the daily help, supervision, and presence that home health doesn't cover. Most West Tennessee families need both: home health for the medical care, Resource One for the everyday recovery support. We coordinate with your home-health agency.
Can transitional care start the same day as discharge?
Often yes. We've started care directly from hospital discharge for many West Tennessee families. Calling us 24 to 48 hours before scheduled discharge gives the cleanest handoff. Same-day starts are possible when discharge timing changes unexpectedly.
Does insurance cover transitional home care?
Original Medicare does not cover non-medical home care. Some Medicare Advantage plans cover limited supplemental benefits — check your plan. Long-term care insurance often covers transitional care once benefits have triggered. The VA Community Care Network may cover post-discharge care for eligible veterans. Most transitional care is paid privately, especially for the first 30 days after discharge.
How long does transitional care typically last?
Most assignments last 2 to 6 weeks. Orthopedic surgery recovery is often 4 to 8 weeks; cardiac and major abdominal surgery 6 to 12 weeks; post-stroke care can last longer and may transition to permanent home care. We taper hours as recovery progresses.
Will the same caregiver be there the whole time?
We aim for consistency, especially during the early high-risk weeks. For full-day coverage, expect a small rotating team of caregivers rather than one person covering 12-hour days for weeks at a time.
Can you coordinate with our home-health agency or surgeon's office?
Yes — that coordination is one of the main reasons families use a licensed agency for transitional care. We share care plans with your home-health nurse, communicate with your surgeon's office about post-op concerns, and step back when home-health is in the home so we're not duplicating coverage.
What's the most common reason families call you for transitional care?
Three patterns dominate: orthopedic surgery (hip, knee, shoulder) where the surgeon discharges someone who lives alone; post-stroke discharge where the family realizes mid-recovery that they can't sustain 24/7 care; and recovery from a fall, where the elderly parent insists on staying home but isn't ready to be alone.
We're worried about readmission — does transitional care actually help?
Yes. Studies of post-discharge support consistently show fewer readmissions when there's professional supervision in place during the first 30 days. The major drivers of readmits — missed medications, falls, missed follow-ups, dehydration — are exactly what an in-home non-medical caregiver helps catch and report. We don't treat or administer; we observe, remind, escalate to your home-health nurse, and keep the daily routine on track. That combination materially reduces the things that send people back to the hospital.
Related services
Ready to move forward with Transitional Care?
We'll walk you through options, timelines, and funding — whether it's in this conversation or after a free in-home assessment.