8 Tips for a Successful Transition Home


Transitioning a loved one home from the hospital can be overwhelming. Our transition team coordinates the transition home from start to finish, so families can focus on what really matters—supporting their loved ones.

Nancy Tafoya, CRRN, BSN, MA, Director of Nursing at Independence Plus, Inc.

Home Is Where the Heart Is

“I always thought the home was the best place for my patients, even before I learned about skilled hourly home nursing,” says Nancy Tafoya, CRRN, BSN, MA, Director of Nursing at Independence Plus, Inc.

A nurse for the last 33 years, Nancy has always felt a strong connection to helping patients maintain the highest quality of life and independence, whether she was working in the ICU or at a transitional care facility.

Nancy was Independence Plus’ first dedicated transition nurse. Today, she oversees a team of three full-time transition staff, plus our Assistant Director of Nursing, Clinical Managers, Education Manager, and Home Nursing Residency Manager.

Last year, Nancy was appointed to the Board of Directors at NIARN (Northern Illinois Association of Rehabilitation Nurses). In this role, Nancy is tasked with educating local hospitals and facilities about the importance of rehabilitation at home.

Transition to Home Care

Earlier this week, we traveled with Nancy to Shriner’s Hospital for Children where she co-presented “Transition to Home Care” with Krista Bauman, MSW, LSW. Nancy and Krista talked about the importance of care coordination between the hospital and home care agency.

“If I have one piece of advice for creating a smooth transition home, it’s planning and preparation,” Nancy shares during the presentation.

Here are Nancy’s tips for patients and families planning a transition home:

  1. Create a Detailed Plan: Meet with all of your home care providers to create a detailed plan for the transition home. For example, how will you travel home from the hospital (ambulance or car), and who will assist with the transition?
  2. Training and Education: Become an expert in the hi-tech equipment and care for your loved one through training and education from our transition team, which includes nurses and respiratory therapists.
  3. Go Shopping! With nurses in the home, you’ll need extra supplies, such as hand sanitizer, paper towels, and toilet paper.
  4. Living Space: Determine the location of patient living space, either a bedroom or larger space such as the living room or family room.
  5. Set Up: Set up the living space with supplies, equipment, and personal items.
  6. Modifications: Determine whether you need to make any modifications to your home, such as adding a ramp or making changes to your kitchen or bathroom to make it more accessible.
  7. Be Prepared! Check entrance and exit routes and the electrical power to maintain patient safety.
  8. Welcome your loved one home with open arms!


Grow With Us

We’re expanding our services and offerings. We want you to be a part of the team that is delivering personalized, individual, people-focused skilled home healthcare to those in need. Come join us.

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