End of Life Care Services
Transitions offers the highest quality of end of life care, symptom management, and primary care services. We specialize in supporting individuals and families who are facing the physical, emotional, social, and spiritual challenges confronted when dealing with terminal and chronic illnesses. Paramount to our philosophy is to ensure that our patient is experiencing their final transition on their own specified terms — in comfort and with dignity. In our care, our main objective is always to maximize patients’ comfort and quality of life.
For us, whether it is end of life, symptom management or primary care – it is always about living. That is why we provide patients with a comprehensive care plan led by a dedicated interdisciplinary team.
The Transitions Difference
end of life care
At Transitions, we go the extra mile to maximize our end of life care patients’ comfort in their final days. Our teams – which include physicians, advanced practice nurses, registered nurses, certified nurse aides, social workers, bereavement specialists, chaplains, dietitians, and volunteers – collaborate with our patients and their families to create an individualized care plan. Once the care plan is in place, we commit to uncompromising demands of hospice care that set us apart from our competition: 24/7 nursing, 24/7 social worker and counseling resources, and extended bereavement support for the family long after the patient has passed.
We aim to empower patients and families by providing the tools and support necessary to embrace life. We don’t focus on the finality of death; we focus on the practical side of living. When the time does come, our philosophy is to ensure that our patients experience their final transition on their own specified terms — in comfort and with dignity. We consider it the responsibility of our care teams to be with the patient in their final moments – so, we have nearly a 94% rate of making sure that “no one dies alone”, a number much higher than the industry average of 15-18%. Above all else, our efforts aim to ensure that the final stage of life comes with the most comfort, peace, and happiness possible.
What is End of Life Care?
Unfortunately, the word most associated with “hospice” is “death.” At Transitions, if anyone asks us to describe our End of Life Care in one word, we would say that word is “living”. Hospice does not hasten death or prolong life. At Transitions, we focus on making every day a quality-filled, comfortable day. We want to support you in the goal of ensuring you or your loved one are able to focus on enjoying the present.
End of Life Care is appropriate when curative treatments are no longer available or wanted, and the life expectancy of the patient is six months or less. Although a six months or less diagnosis is required for admission, hospice care does not stop after six months. If a patient lives longer than six months after admission, hospice services remain as long as the patient still qualifies to continue receiving comfort focused care rather than curative treatment.
Transitions’ care team can provide care in your home, wherever you call home – a private residence, a senior living community, assisted living or long- term care facility. The hospice team includes specially trained Hospice Physicians, Registered Nurses, CNAs, Social Workers, Chaplains, Volunteers and Bereavement professionals to provide layers of support and holistic care throughout the patients time on hospice. These services come at no cost to the patient, as Hospice is covered under Medicare, Medicaid, most private insurances, and Veteran benefits.
Appropriate individuals may exhibit some or all of the following:
Deteriorating mental abilities
Illness causing a limited life expectancy of 6 months or less
Progressive weight loss
Specific decline in condition
Choosing care that focuses on symptom management and quality of life rather than curative treatment
The Four Levels of End of Life Care
Routine Home Care is the most basic level of hospice care. In this stage, care teams serve patients wherever they reside. The team includes registered nurses, advanced practice nurses, certified nurses aides, social workers, volunteers, physicians, dietitians, and chaplains. Transitions offers a comprehensive plan of routine care that is tailored to each patient’s needs. Medications and medical equipment will be brought directly to the patient or caregiver via Transitions Medical Equipment and visits from the Transitions care team will occur frequently in order to meet all of the patient’s needs.
Continuous end of life Care
In this level of care, a nurse or certified nursing aide (CNA) will remain at the bedside for as long as the patient qualifies for continuous care. When the patient is experiencing symptoms that cause severe pain and require frequent interventions, such as medication administration, the patient will qualify for this level of care. The goal of continuous care is to get a patient’s symptoms under control to a point where they are manageable with routine end of life care. Continuous care is important because it allows the patient to remain at home through a difficult time instead of being uprooted into a hospital.
Some examples of acute conditions that may require continuous end of life care include: uncontrolled pain, trouble breathing, extreme nausea, changes in consciousness, and seizures.
When symptoms require an advanced level of care that is beyond routine or continuous care, a patient will enter the “inpatient” level of end of life care. This often occurs when the patient needs 24-hour pain control or acute or complex symptom management that cannot be provided at home. In its entirety, the goal of inpatient care is to control severe pain and symptoms so that the patient can return home to familiar surroundings and continue with routine end of life care. This level of care can be provided within a skilled nursing facility, hospital, or any facility contracted to operate an inpatient unit.
The fourth level of end of life care is respite care, where a home hospice patient is admitted into a facility for a short period of time. The goal of this care is to provide a short-term break for family caregivers who are assisting a loved one with an advanced illness. These services can be offered at any hospital, hospice facility, or skilled nursing facility that is able to provide 24-hour care. It is essential that those taking care of loved ones are able to take breaks and avoid “caregiver burnout”. These “breaks” can last up to 5 days and plans for respite care are developed directly with family members of the patient.
We love hearing from you!
“We are most grateful to you. Everything seemed to happen so rapidly, but you were all right there, offering your services, your support and keeping us informed. Thank you. You provided great comfort. May your work continue and spread.”
When is it Time for End of Life Care?
End of life care is for you or your loved one when curative treatments are no longer available or wanted and the life expectancy of the patient is determined to be six months or less by a practicing physician. Often, the patient’s doctor will refer them to Transitions, after which our team will conduct an initial evaluation and begin caring for the patient. Although a six months or less diagnosis is required for admission, hospice care does not stop after six months. If a patient lives longer than 6 months after admission, end of life care services remain as long as the patient still qualifies and chooses to continue receiving comfort focused care rather than curative treatment.
If you would like to receive curative treatments while still benefiting from Transitions Care services, we would advise you to visit our palliative or primary care pages for further information.
Guidelines for End of Life Care Evaluation
Does the patient have a terminal diagnosis?
Recurrent falls, infections, or hospitalizations?
Family/Patient no longer wants aggressive treatments?
Weight loss or decreased appetite?
Decline/Change in mental status?
Decline in ability to perform ADLs?
Common End of Life Care Diagnoses
Most common end of life care diagnoses includes, but not limited to:
Cancer — cancer malignant/metastatic and no longer pursuing curative treatments
Alzheimer’s or other dementias — speech is 6 intelligible words or less a day, decline in ability to perform ADLs, incontinence, may have weight loss and/or infections/UTIs
CVA/Stroke — impaired nutritional status, dysphagia, weight loss
MS, ALS or other neurological diseases — impaired breathing/swallowing, weight loss, infections, wounds
Liver Disease — INR > 1.5 or Albumin < 2.5, hepatic encephalopathy, malnutrition
End Stage Renal Disease (ESRD) — refuses dialysis, creatine > 8 ( > 6 for diabetics)
Cardiac Disease — symptoms (edema, chest pain, SOB) persist despite optimal medical treatment
COPD/Respiratory Failure — oxygen dependent, dyspnea at rest, tachycardia, pulmonary infections
Who Pays for End of Life Care?
End of life care is covered by Medicare, Medicaid, most private insurance benefits, as well as Veterans Affairs (VA) benefits. Most of the time, there is no cost to the patient or the family under the End of Life Care Benefit. The benefit covers all medications, equipment, supplies and services related to the end of life care diagnosis. This includes:
Registered Nurse visits
Certified Nurses Aide visits
Durable medical equipment and supplies
Spiritual, emotional, social, dietary, and other counseling services
Access to Trained volunteers
Music Therapy, Massage Therapy, and other ancillary services
Grief and Bereavement services
At Transitions, we strive to go above and beyond for our patients. In addition to the benefits outlined above, we also provide our patients with following services at no extra cost:
Assistance when filling out Medicaid (Public Aid) applications
Aid in finding community resources for social and emotional support
Life Enrichment services to make the end-of-life about living
Discussing family dynamics and help navigating these dynamics from a licensed professional
Extended grief and bereavement support
Assistance in planning a private memorial service
We love hearing from you!
“Transitions, thank you very much for taking such good care of my mother Suzanne at the end of her life. You made her very peaceful and comfortable."