Earlsfort eHealthwatch

Home Transitional Care

Home Transitional CareWho? / What? / Benefits?

Who is it for?

For hospital patients with severe or complex illnesses, who need extra medical support in the short—term, as they leave hospital and move home.

This service helps people to recover from illness in their home and to return to independent living. Some patients need high-intensity supports at this time and traditionally this transitional care may take place in an acute or step-down hospital. Home Transitional Care offers the support needed in the home that may avoid the patient being re-admitted to hospital after discharge.

The service has been developed around an integrated clinical model and an advanced IT platform.

Intensive health monitoring and nursing care is provided for up to 30 days over the transitional period – giving patients the best possible chance of a successful outcome, given their medical circumstances.

What is covered?

  • The patient receives ongoing expert assessment and intensive medial support at home
  • Health monitoring devices are used as an integral part of the service so that changes in the patient’s condition are remotely monitored by experts e.g. blood pressure, heart rate, blood sugar levels etc.
  • Expert geriatric input to all carer meetings as well as a chronic disease monitoring and intervention programme, allowing us to deliver intensive home monitoring and nursing care for up to 30 days
  • The designated person is contacted e.g. the client, carer or family member and the appropriate action is recommended.


There are multiple benefits of Home Transitional Care for patients however the primary advantage is that it allows weak, elderly people to be treated with dignity, in their own home, with an appropriate level of intensive medical attention. After a difficult period for the person and their family, it opens a window of opportunity to return home in the short-term, despite the level of medical support needed and it facilitates a move towards a higher quality of life at home, in the longer term, where feasible.

The access to medical expertise at home and the ongoing, quality medical monitoring, would previously only have been accessible through admission to a care facility.
It can mean shorter time in hospital, fewer medical emergencies, quicker attention to changes in the patient’s medical status and more comfort for the customer.

However as this is an interim solution, it also provides time for the patient, family, medical team and carers to assess the situation and the outlook for future living arrangements. In the past where no such care has been available, people were forced to make a decision on this without the opportunity to test the option of living at home.

Equally for hospitals, A&E Depts and medical facilities, it offers a real alternative which can free up beds and nursing resources while also giving the patient what he/she often really wants – the comfort of home with the security of expert medical care. The cost savings are easily assessed yet the possible improvement in the quality of life for the patient can be immeasurable.

Why not call straight away to learn about the service +353 (0)1 839 6610 or email for more information. We look forward to your call.

Home Transitional Care

Earlsfort eHealthwatch Limited (T/A eHealthwatch). Registered Number 500631. VAT Number: IE 9799612U Registered in Dublin, Ireland at 74 Eccles Street, Dublin 7, Ireland. Directors: D Power, E Brazil, D Keane