Next Step in Care: Family Caregivers & Health Care Professionals Working Together

Next Step in Care provides easy-to-use guides to help family caregivers and health care providers work closely together to plan and implement safe and smooth transitions for chronically or seriously ill patients.

Transitions are moves between care settings, for example, hospital to home or rehab facility, or the start or end of home care agency services. Because transitions are often rushed, miscommunication and errors can occur.

Next Step in Care materials emphasize careful planning, clear communication, and ongoing care coordination.

View Next Step in Care on your smart phone or other mobile device. See the easy instructional video here.




Home Care and Rehab Guides Updated

The practice of terminating rehab services because a patient has "plateaued" should end as of January 7, when CMS's revised policy manual went into effect. Beneficiaries are entitled to continued services as long as there is a need for skilled services “to prevent further deterioration or preserve current capabilities.” The policy applies to rehabilitation programs in skilled nursing facilities, home health agencies, and outpatient clinics, as well as independent contractors. Physical therapy, occupational therapy, and speech-language pathology are the services covered. Two Next Step in Care family caregiver guides—Planning for Inpatient Rehab  and Home Care: A Family Caregiver’s Guide—have been updated to reflect the changes.

Doctor Visits

A new guide, "Family Caregiver Guide to Doctor Visits," offers family caregivers advice on how to prepare for and manage a doctor visit with a family member.  It addresses two common missteps—staying in the background and failing to ask questions, and taking the lead away from the family member. Learn how to get the most out of the visit and deal with disagreements.

Family Caregivers

If you are caring for a family member, click here for information that can help with patient transitions.

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Health Care Providers

If you are a health care provider (doctor, nurse, social worker, or therapist), click here for information that can help you and family caregivers.

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