Social Work and Care Transitions

Social Work in the home is intended to identify barriers that might interfere with recovery and successful caregiving in the home. Social workers assist with resources such as meals on wheels or transportation options as well as preparing for future needs or crisis intervention.

Social Workers may assist with:

Community resource planning and coordination

Referrals to community agencies

Assistance in emotional adjustments and coping strategies related to illness or life changes

Help access resources related to medical care, medications, food, rent, and other cost barriers

Provide information on long term care options such as assisted living or alternate housing

Suggest support programs for caregivers

Assist with resolving minor family conflicts affecting patient care

Crisis intervention

Grief counseling

Advance directives

Assessment related to depression, anxiety, or memory loss symptoms


Care Transitions Coaching

It’s finally time to go home from hospital/rehab. Let’s Work together to make it smooth.

Many older patients and caregivers go home from rehab to discover ambiguities about care instructions. Many of the common uncertainties (for example unanswered medication questions) can place patients at risk for unfavorable outcomes and even avoidable re-hospitalizations.

Actively preparing for discharge home and asking the right questions, in advance, are effective ways to intercept obstacles that lead to re-hospitalizations. How does one know the right questions to ask?

Axiom Home Care offers a unique solution in the form of a care transition coach who is available to incorporate proven Coleman Coaching techniques to help prepare and support patients through the move from one healthcare setting to the next. The transition back home doesn’t have to be the most confusing segment of the recovery journey, after all.

Here is how it works:

When a home health care referral for Axiom is initiated, a social worker with special training in health care transitions may provide a visit to the rehab facility or hospital in the days nearing a planned discharge date; or to a patient’s home around the time of a move from the hospital or rehab facility to home.

The pre or post discharge coaching visit allows patients to really begin thinking about deeper questions related to their medications, treatments, and symptoms. The coaching model is designed to prepare patients and caregivers with tips and tools, including a personal health record, that will help lead to confident discussions with the doctor and other health care professionals.

Care Transitions Coaches may assist with:

Medication self- management

Identifying red flags for an individual’s health situation

Continuity of care

Setting personal health goals

Planning steps towards improved health and wellbeing

Preparing for conversations with the primary care doctor and specialists

Preparing for conversations with other health professionals

Initiating a personal health record

Improved patient and caregiver communication

When is Care Transitions Coaching Beneficial?

When discharging from a hospital to home

When discharging from a skilled nursing or rehab facility to home

When moving into a senior community or assisted living environment

When a new life altering medical condition has been diagnosed such as Diabetes, Heart disease, COPD, or Blood Pressure fluctuations

When family caregivers take on new caregiving tasks for a loved one

Does Transition Coaching Really help?

The “coaching” approach to care transitions is based on years of research by a geriatric doctor in Denver Colorado. The years of studies behind the approach have consistently resulted in significant reductions in patient re-hospitalizations when “coaching” techniques are faithfully applied.


If you know someone who is planning a rehab stay or who has been surprised by an unexpected illness or accident; they may be an ideal candidates to benefit from a Transition Coaching session as part of a home health care episode. Please call Axiom Home Care today at 734-324-3166 to learn more.


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