Coach without a whistle

T’is the season of Christmas parties, and a fairly standard question at any festive get-to-together is, “How’s the Eggnog?”  A good answer is: “Eggnog is bad for you, the only thing worse here is that bottled water from the Super-Fund site.  Try the green tea instead.”

Another question is: “What do you do for a living?”  My answer: “I’m the Transition Coach for Concierge at Home.”  I get alot of blank stares after that, maybe a polite, “Oh, what is that?”  It’s a shame that more people aren’t familiar with the concept, because I really think it is one of our key services.

Here’s the Official Definition:

The American Geriatrics Society defines transitional care as follows: Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing homes, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

A good definition, but it’s a tad wordy to use at parties.  Here’s how we define it:

Someone you already know helping and guiding you and your family through a bad time.

For example, let’s say your family member goes to the ERtoo many cooks with a broken leg/shoulder/hip/heart-attack/whatever.  If they are not admitted to your normal general practitioner, they get attached to a hospitalist.  The hospitalist picks a surgeon/cardiologist, who might also consult another specialist if things get complicated.  very quickly you can have three to four doctors all involved in your family members care, even more when you consider all the different folks in the hospitalist service who may get into the mix.  Now this is not necessarily a bad thing, but it can be very confusing.  All of those doctors have to agree and get lined up before discharge.  But what if you are being discharged home?  What if you’re not going home but to rehab, or short stay in a nursing home?  Who keeps track of all of this?

I do.  I follow our patients through the hospital stay, keeping track of all the different things going on and making sure the patient and the family really understands what is happening each step of the way.  And when it’s time to move back  home or to go another facility,  I go right along with my patient.  My job is making sure what is supposed to happen happens when it’s supposed to happen.

There’s quite a bit of research on this topic, but we’ll talk about it more later.  Right now, it’s your turn.  Please use the comment section below, and let me know what you think.


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