How a Patient Advocate Can Help With Transitional Care

When a person is discharged from a hospital or rehabilitation facility, the journey to full recovery is far from over. This critical phase, known as transitional care, often determines whether someone heals safely at home or ends up back in the hospital.

For older adults, elderly patients, or those with complex care needs, a misstep during this time can lead to dangerous medication errors, unmanaged chronic conditions, or poor self care practices.

This is where a patient advocate like Stephanie “Stevie” Kiziukiewicz of Seawind Health Advocacy Group becomes indispensable.

Understanding the Risks of Poor Transitional Care

Discharge from a hospital or rehab facility may sound like a milestone, but it often leads to new challenges. People return home still weak from acute illness, unsure about medications, and struggling to follow instructions. Cognitively impaired older adults face even greater difficulties understanding their treatment plans or remembering follow-ups.

The health care system is fragmented, and communication among health professionals and caregivers can be inconsistent. Without coordination, patients risk getting readmitted to the hospital within six months, or sooner. According to healthcare research and organizations like the National Institutes of Health, poor care transitions are linked to worse patient outcomes, including emergency room visits and an overall decline in well-being.

What Is Transitional Care?

Transitional care includes a wide range of services aimed at helping patients shift from one care setting to another. This can involve:

Ensuring follow-up appointments with physicians and specialists
Coordinating with home health providers, nursing staff, or therapy teams
Educating family members and caregivers about red flags and recovery expectations
Preparing a comprehensive care plan with clear next steps

The goal is to bridge the gap between the hospital and home, while minimizing confusion and reducing risk.

The Role of a Patient Advocate in Care Transitions

A patient advocate is a trained professional who understands the intricacies of the health care landscape.

At Seawind Health Advocacy Group, Stevie Kiziukiewicz provides clients with:

Personalized Discharge Planning

Stevie works directly with healthcare providers, hospital staff, and rehabilitation services to ensure each discharge plan is thorough and patient-centered. She reviews discharge summaries, checks for gaps, and confirms all services are in place before the patient even walks through the door.

Coordinated Communication

A major challenge in care transitions is communication. Stevie acts as a bridge between physicians, nurses, therapists, and family caregivers, ensuring everyone is aligned on the plan of care. She helps interpret medical language into plain English and facilitates conversations that support better health decisions.

Education for Families and Patients

Family caregivers are often thrust into a role they didn’t anticipate. Many are managing complex care without training. Stevie provides ongoing education so they can make informed choices. She also teaches patients about monitoring symptoms, managing chronic diseases, and building self care routines.

Home Safety and Service Access

Transitioning home can be hazardous if physical spaces aren’t adapted for patient needs. Stevie helps arrange services like home safety assessments, durable medical equipment delivery, and access to resources such as transportation, nutrition, and visiting nurse care.

The Evidence Behind Transitional Care Models

Research shows that certain transitional care approaches—like the Transitional Care Model and the Care Transitions Intervention—significantly reduce hospital readmissions and improve patient satisfaction. These models emphasize:

Partnering with a consistent transitions coach
Early follow-up and continuing continuity across care settings
Engaging family caregivers and the patient in care planning
Monitoring progress for six months post-discharge

patient advocate helping client new jersey

A prominent researcher in this field, Coleman EA, demonstrated that intervention designed to improve communication and continuity of care leads to better outcomes for older adults, particularly those managing multiple chronic conditions.

Supporting Cognitively Impaired and Elderly Patients

Cognitively impaired older adults face unique risks, including confusion about medications, appointment schedules, and therapy routines. As a Certified Dementia Practitioner, Stevie understands how to communicate effectively with patients who have memory loss, and how to educate their family caregivers with compassion and clarity. Her expertise ensures no one is left struggling with overwhelming medical instructions.

Advocating for the Whole Family

A patient advocate doesn’t just support the patient—they also support family caregivers. When an aging parent or spouse comes home from the hospital, children or other family members often carry the emotional and logistical burden. Stevie steps in to share that load.

She helps families:

Navigate insurance coverage and out-of-pocket costs
Coordinate rehabilitation services, home care, and therapy
Plan for future care needs or possible decline
Communicate with multiple providers across the health care system

This support protects caregivers from burnout, reduces stress, and promotes a healthier home environment for recovery.

Why Professional Advocacy Matters

Transitional care isn’t just a checklist—it’s a vulnerable, high-stakes time. Having a professional advocate like Stevie involved means there’s someone who will:

Focus on the person, not just the patient
Monitor transitions closely across care settings
Improve access to timely services and resources
Anticipate complications before they escalate
Elevate the voices of both the patient and their caregivers

Her role isn’t to replace healthcare providers, but to partner with them, making the health care experience safer, clearer, and more compassionate.

How to Get Started With a Patient Advocate

If you or a loved one is preparing to transition from a hospital or rehab facility, don’t wait until problems arise. Engaging a patient advocate early can change the entire trajectory of healing.

At Seawind Health Advocacy Group, Stevie offers personalized consultations for residents of Ocean and Monmouth County, New Jersey, as well as virtual sessions for those farther away. Her work is grounded in empathy, backed by professional certifications, and guided by real-world experience.