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Why Care Transitions Are Where Families Need the Most Support

Care transitions—such as hospital to home or rehabilitation back to independent living—are some of the most vulnerable moments in healthcare. During these transitions, patients and caregivers are expected to absorb complex instructions, manage medication changes, and coordinate follow-up care, often with little guidance. This is where confusion, miscommunication, and preventable setbacks most commonly occur.

What Are Care Transitions?

Care transitions occur whenever a patient moves from one setting to another, including:

  • Hospital to home
  • Hospital to rehabilitation
  • Rehabilitation to independent living
  • Specialist care back to primary care

Each transition requires accurate communication and coordination.

Why Transitions Increase Risk

Discharge instructions are often delivered quickly. Medication lists change. Follow-up appointments may not be scheduled. Families are expected to manage these changes while already under stress.

These gaps are not the result of poor caregiving—they are systemic.

Where Communication Breaks Down

Information often fails to transfer smoothly between providers and settings. What one team assumes has been communicated may not be fully understood or documented.

How Advocacy Supports Continuity of Care

Patient advocates help by:

  • Reviewing discharge instructions in plain language
  • Confirming follow-up plans
  • Supporting communication across providers
  • Helping caregivers know what to monitor at home

Why Transitions Deserve More Attention

Transitions are not administrative moments; they are clinical risk points.

Care transitions are not minor administrative moments—they are critical points in a patient’s healthcare journey. When instructions are unclear or follow-up is incomplete, the risk of confusion and setbacks increases significantly. Support during these transitions helps ensure continuity, understanding, and safer outcomes. Families should not be expected to manage these handoffs alone.

Understanding care transitions can prevent avoidable setbacks.

LORI IS EXTREMELY TALENTED!

What a great use of Lori’s talents!

I worked with Lori for several years during my career as an orthopedic surgeon. I know her to be not only compassionate and understanding but also a tireless advocate for what is right.

In difficult situations she was unwavering in her quest to enable me to provide the best possible care for my patients. She knows the system and how to work through it (and around it whenever necessary

LORI JUMPED RIGHT IN

If you are in need of a patient advocate, I would highly recommend Lori Schellenberg. She is extremely knowledgeable, effective, and professional. Knows when to be strong and forceful yet loving and caring with your loved one and your family. I was concerned about an elderly family member who had several severe falls, was forgetting to take medication, not eating healthy and not keeping up with housekeeping yet insistent she was fine and staying in her home. Even though Lori lived out of state she made phone calls on our behalf, made several recommendations to help us provide what our loved one needed and was an intermediary when it was necessary. Lori’s knowledge of geriatrics, continuous care/assisted living facilities, the health care system, long term care insurance and hospice is invaluable. She helped us put together a plan that provided the best and continuous care necessary for our loved one and our family. We are extremely thankful for her help and look forward to continuing to work with her as our loved one moves through the next phases of her life’s journey, thus enabling us to create loving memories.

LORI JUMPED RIGHT IN

My husband underwent nasal surgery 6 months ago, after he had a negative sleep study test and was referred to an ENT doctor due to continued fatigue and snoring.

Unfortunately, he developed two different serious infections, and we were concerned about his ongoing treatment with the ENT. In fact, we were very anxious because he wasn’t getting better but the surgeon was not clear with us as to what to do next.

When describing what was going on, Lori jumped right in, when she found out my husband was actually at the surgeon’s office at that time, and still did not understand the situation. She recommended that my husband ask to have the surgeon come back into the room, and to call her so that she could speak to the surgeon with my husband in the room. Lori was very professional and knowledgeable in her approach with his surgeon. She established a treatment plan, in a way that my husband could understand, and why this was the plan. She also discussed the “what ifs” the current treatment plan did not work. He ordered further tests to be completed prior to his next appointment, if he did not improve.

She followed up with my husband and I to make sure we understood the plan.

By advocating for my husband, Lori relieved a lot of anxiety and stress that this current medical concern was causing, and they felt more confident in the surgeon’s care.

We highly recommend Lori and Stepping Stone Advocacy Services, if you are experiencing a medical condition, and don’t know where to turn for answers. She is experienced and professional, yet able to discuss medical terms in a way that we understood.