Last updated: April 10, 2026

Did you know hospital readmissions are a leading concern in the care industry? In fact, there were about 3.8 million adult hospital readmissions within 30 days of discharge in 2018, and of those, the average readmission cost was $15,200.¹

After an extended hospital or rehabilitation stay, the first days at home can feel uncertain. Medication schedules, mobility challenges, and gaps in care can put recovery at risk. Fortunately, an effective transitional care program, such as our GoHomeWell™ post-medical care program, helps bridge these gaps by identifying risks early, coordinating care, and delivering tailored support for smoother recoveries and reduced risk of hospital readmission.

 In this article, explore the benefits of transitional care and the critical role it plays in the continuum of care. You’ll also learn more about GoHomeWell™ and how it can provide the right support for your family and loved one during recovery.

Transitional Care Management vs. non-medical transitional care

First of all, it’s important to understand the distinct difference between transitional care and Transitional Care Management. While both aim to fill gaps in care, ensuring a smooth transition and a successful recovery and reducing readmission to the hospital, they differ greatly in approach, eligibility, and time sensitivity. Here’s a quick breakdown.

What is Transitional Care Management?

Transitional Care Management refers to a set of Medicare-billed healthcare services provided to eligible patients following discharge from a hospital or other qualifying healthcare facility. It involves a structured process to support patients during their transition between care settings. Typically, it’s available within the first 30 days after hospital discharge and has eligibility criteria, formal healthcare service requirements, and limits as to who is qualified to provide Transitional Care Management services.²

What is transitional care?

Transitional care refers to a broad set of non-medical services designed to ensure a safe transition as a client moves between different care settings or levels of care. It often works in tandem with healthcare transitional care to ensure a smooth and holistic transition and does not have eligibility requirements. Non-medical transitional care helps ensure care continuity at home by helping to fill gaps sometimes left by medical services.

What can be expected from transitional care?

From a home care perspective, transitional care involves providing comprehensive support to clients as they move from a hospital or facility setting back into their homes. Those who benefit most include older adults, individuals with chronic conditions, or those recovering from acute illnesses or surgeries as they return home. One might also consider transitional care services if they require assistance with daily activities during their care transition, need help managing medications or following discharge orders, or are at risk of readmission to the hospital due to inadequate lifestyle factors.

To help ensure a seamless transition and promote quality recovery in the comfort and familiarity of their own home, the following services are often involved in at-home transitional care:

• Medication reminders
• Care coordination between care professionals
• Transportation to medical appointments or follow-up visits
• Mobility assistance
• Bathing assistance
• Light housekeeping
• Daily grooming
• Grocery shopping
• Meal preparation
• Pet assistance
• Companionship and socialization

What are the benefits of transitional care?

Transitional care offers numerous potential benefits for clients and care providers alike, including:

• Lower risk of hospital readmissions. Proper transitional care ensures clear communication between clients, care providers, and caregivers, which minimizes the risk of miscommunication about medications or treatment plans that could lead to complications or gaps in care. For instance, through our GoHomeWell program, we track readmissions amongst clients and communicate that data to our agencies to substantiate their services and help lower their readmission rates.
• Adherence to discharge instructions. Professional care providers are by the client’s side every step of the way to ensure discharge instructions are being done properly and at the correct time and frequency.
• Enhanced problem-solving. As clients’ needs are closely monitored, any problems or complications that arise can be discovered early and addressed quickly. This significantly helps prevent further issues from coming up later on down the road.
• Cost-efficient care. Transitional care aims to avoid unplanned hospital readmissions and instead uses resources more efficiently, resulting in notable savings.
• Supervision and companionship. Not only does the person receiving care get regular daily companionship through their care provider, but they can also get access to other community resources, depending on their treatment plan and health needs. This can help address deeper needs that may have otherwise gone unnoticed.
• Better client experience. Transitional care often focuses on client education, which empowers the person receiving care to learn about their condition and treatment plans. This approach gives the client and caregiver the tools they need to manage the condition at home and aids in quicker recoveries and overall better health outcomes.

Where can I find a transitional care program?

A transitional care program is a structured and organized framework used to deliver transitional care safely and effectively. If you or a loved one are expecting an upcoming care transition, consider HomeWell’s post-medical care Signature Program, GoHomeWell.

At HomeWell, we believe compassionate assistance during the transition home can drastically improve long-term outcomes for both the individual in recovery and their family. GoHomeWell eases the transition back to home life by supporting each individual’s unique recovery needs through a holistic care approach, an adaptive care plan, and ongoing assessment and monitoring. To learn more and find help, schedule a consultation with HomeWell today.

Sources

1. Weiss, A. J., Jianh, H. J. (2021, July). Overview of Clinical Conditions With Frequent and Costly Hospital Readmissions by Payer, 2018. HCUP Statistical Brief #278. Agency for Healthcare Research and Quality, Rockville, MD.
2. (2024, July). Transitional Care Management Services. Centers for Medicare and Medicaid Services.

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