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Stanford Health Care

Transitions of Care

Senior Care

Transitions of Care

The Transitions of Care program provides education, resources, and care coordination for vulnerable adults residing in San Mateo, Santa Clara, or Alameda counties. Once a referral is placed by a hospital clinician, patients are offered services for up to 60 days after they are discharged from Stanford Hospital or from post-acute facility, to home. The Transitions of Care team includes nurses, social workers, a geriatrician, a pharmacist, and an occupational therapist.

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Care and Treatment

Important Legal Documents

There are several documents available to record health care wishes for you or your loved one who may become unable to make decisions due to illness or incapacity.

Advance Directive

An advance directive is a legal document that allows you to list your preferences for medical decisions in the event you are unable to communicate or make decisions for yourself.

With regard to an aging adult, it is especially important to think about and document health care wishes. This document can help ensure that your family and care team understand your wishes for medical treatment, such as end-of-life care and organ donation.

  • For those patients who have been admitted to Stanford Hospital, advance care directives are available through Guest Services at 650-498-3333. You may also pick up an advance directive from the Health Library at no charge.

Physician Orders for Life-Sustaining Treatment (POLST)

POLST translates a patient's goals for care at the end of life into medical orders to be followed by medical professionals. POLST is a legal document that allows doctors to assess and convey the wishes of patients at advanced ages, or with serious illnesses.

POLST is a relatively new document that updates the traditional DNR (Do Not Resuscitate) form and provides additional instructions about what interventions are acceptable.

Durable Power of Attorney (DPOA)

As a caregiver, there are limits to what information you can access without written legal permission. A power of attorney grants you the right to make legally binding decisions for the person who grants you that authority. Power of attorney can be granted for health care and for finances, allowing you to step in when necessary.

A DPOA for health care or finances stays in effect even if the person granting the authority can no longer make decisions, either temporarily or permanently. A DPOA ensures end-of-life wishes and financial allocations are followed.

Health Insurance Portability and Accountability Act (HIPAA)

Make sure a HIPAA release is signed as a patient's medical information will remain private without a release, even with a DPOA.

Stanford Health Care Now

For Patients

Stanford Health Care is known worldwide for the advanced patient care provided by its doctors and staff. We also provide a wide range of guest services and amenities to our patients and visitors. Learn more about preparing for a hospital stay, billing and financial services, and our other support programs in Patients & Visitors.  

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650-723-1303
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 Referrals to Transitions of Care are made internally by Stanford providers. For more information, please call 650-723-1303.