Transitional Care

Mom comes home on Thursday. Who's there Thursday night?

That's the question worth asking before discharge day.

The earlier you call, the more time we have to understand what help is needed and determine whether we can arrange the appropriate coverage. When possible, we begin planning with the family and discharge team before the person leaves the hospital or rehab. A Client Relations Manager will talk with you about mobility, daily routines, overnight needs, meals, medication reminders, and follow-up appointments. Recovery looks different for everyone. Someone returning home after surgery may need longer shifts at first, followed by shorter visits as independence improves. After a more complicated illness or hospital stay, support may be needed for longer.

We'll discuss the schedule that makes sense for your loved one's needs and adjust it as circumstances change. You pay for the hours of care provided, according to your service agreement. When care is no longer needed, you can end the service in accordance with that agreement. Assured Assistance does not provide live-in care.

We'll build a plan around your loved one—not a generic schedule—and discuss what care can be arranged before the first shift begins. A Client Relations Manager talks to you, and to the discharge planner if you'd like, about what the first week needs. How much walking, whether she can be alone at night, the new medications, who drives to the follow-up. The office builds a schedule for that week, not a generic one, and the first shift lines up with the discharge. And if more is needed, our Case Manager Kristin Galle, RN, BSN, is available to assist as you need. Case management can help with care coordination and appointment advocacy, while home care provides the everyday, non-medical assistance. This extra assistance is a real advantage.

Helping Make the Transition Home Safer

The first days at home can be overwhelming. There are new routines to learn, instructions to follow, and concerns about whether everything is going as it should. Our caregivers help with the everyday needs that can make recovery at home easier for both your loved one and your family.

• Medication reminders: Follow established medication protocols as per care plan
• Getting around safely: Providing appropriate assistance with everyday mobility and keeping needed items, such as a walker, within reach.
• Meals and nutrition: Shopping for groceries, planning/preparing meals, and offering companionship at mealtime.
• Noticing changes: Sharing concerns about changes in appetite, alertness, swelling, or general well-being with the family and appropriate healthcare professionals.
• Follow-up appointments: Helping arrange transportation and accompanying your loved one when appropriate.

Home Care and Home Health Work Together

Assured Assistance provides non-medical home care. Our caregivers help with daily routines, personal care, meals, mobility, companionship, and other needs outlined in the care plan.

They do not replace skilled nursing or perform medical procedures such as wound care or injections. When home health services are involved, our caregivers can provide complementary support with everyday needs while your loved one receives care from the appropriate healthcare professionals.

One family's journey home

Home Was Where They Wanted to Be

At 94 and 95, a Berks County couple faced a difficult decision after a fall led to a stay in a personal care setting. But home was where they wanted to be—and with the right support, their family was able to help make that wish a reality.

Assured Assistance caregivers became an important part of their everyday lives, helping with meals, personal care, housekeeping, laundry, and the many little things that make a house feel like home. As their needs grew, our care grew with them. What began as help with daily routines became more hands-on support, giving them the opportunity to remain in the place they knew and loved.

When hospice became part of their journey, Assured Assistance continued providing care alongside the hospice team. As both became bedbound, our caregivers provided around-the-clock support in shifts, helping with their daily needs and offering a familiar, caring presence through life's most difficult moments.

She passed away at home. About six months later, he did too—at home, just as he had hoped.

Home care is about so much more than helping with daily tasks. It's about making it possible for people to remain where they feel most comfortable, surrounded by familiar things and the life they've built. For this couple, that meant being home until the very end. And we were honored to be part of making that possible.

If your family is facing a similar decision, you don't have to figure it all out alone. Let's talk about your loved one's wishes, the help they need, and how Assured Assistance may be able to support your family in making home possible.

With the family's permission, Sherry shared their story in Home Is Where They Wanted to Be.