With a significant number of patients suffering from critical ailments being re-admitted to hospitals after being discharged, the shortcomings in the healthcare industry are evident more than ever before.

Even the most advanced critical care management system fails to ensure holistic recovery in the absence of follow-up care. Therefore, it is imperative to ensure efficient utilisation of critical care facilities for improved patient outcomes. This is the context where transition care gains importance in India's healthcare scene.

Most major medical/surgical illnesses are sudden, unanticipated and need a tertiary care facility to manage them. After the critical care is over, the patient desires to get discharged from hospital and go back home. But this is not always possible. Though treatment at the hospital may be over, complete recovery takes a while. Most patients who have suffered a severe injury or illness require additional, consistent and specialised care to get them back to their routines. To recover completely, specialised services like nursing care and physiotherapy are a must in some conditions.

As we know, a healing body needs a nutritious diet to recoup well. This clearly reinforces the involvement of multiple parameters in the complete recovery of an individual. Overcoming a critical ailment is not just about physically fighting back a condition, but also involves combating the emotional turmoil that creeps in. After major illness/surgery in specialties like neurology, orthopedics and cardiology, this specialised requirement is a must, rather than preferred.

This special category, called transition care, is a part of the health care canvas in any mature health care model operational in European or other Western countries. And the good news is that India is finally waking up to this new model. The need is even more now as tertiary care has evolved exponentially and is almost at par with the best of global services. For someone who has benefited from tertiary care services, the ideal solution would be to undergo transition care so that recovery is quick, complete and minimises the scope of readmission/post-op complications.

An ideal transition care facility is the perfect place where holistic care is provided by an experienced, multidisciplinary rehab care team in a state-of-the-art facility. It will ensure an early, effective and empowered recovery and help patients return to their routine, to the extent possible.

Neurology, orthopedics, cardiology and oncology are the primary specialties that almost mandate transition care services for individuals recovering from major illnesses under these conditions. For the following major diseases from each of these specialties, there are well-established clinical outcomes that indicate the integral role played by transition care services.

• Neurology or neurosurgery: Stroke, spinal cord injuries and traumatic brain injuries are the key ailments which benefit from transition care services. The duration of transition care might range from a few weeks to some months depending on what exactly a patient desires to achieve before going home.
• Orthopedics: Hip or knee replacements commonly need a transition period of specialised care. The usual range is between two-three weeks for a proper transition to home. Cardiology: Early mobility, positive lifestyle modification and prevention strategies dominate for cardiology patients who have gone through major procedures.
• Oncology: Medical supervision, monitored nutrition and emotional support are the key requirements for most of the early oncology cases while they go through primary treatment with the oncologist or onco surgeon. A transition care facility is the right place to get all three.

A multi-disciplinary rehabilitation care team is key to transition care. Doctors, nurses, physiotherapists, dietitians, psychologists, occupational therapists, speech therapists and respiratory therapists play a major role in achieving total recovery in an ailing patient. While these practitioners usually work in silos in hospitals, transition care providers ensure they collaborate in overall patient care for a holistic recovery, which includes physical recuperation as well as achieving emotional stability and quality of life.