Need: To prevent hospital readmissions and improve the recovery process for older adults in rural southern Ohio.
Intervention: Hospital2Home identifies individuals who have an elevated risk of hospital readmission and provides vouchers for services like personal care and home-delivered meals.
Results: In each of the six years the program has been in operation, over 85% of participants have avoided readmission in the first two months after hospital discharge.
In the rural southern region of Ohio, there are few
personal care resources and limited transportation
options for older adults after they have been discharged
from a hospital. Limited social contacts and fewer
available caregivers also contribute to an elevated risk
of hospital readmission.
In 2017, the Area Agency on Aging District 7, Inc. (AAA7)
began the Hospital2Home program to help older adults in
this 10-county region transition from the hospital to
their homes. This program gives eligible patients
vouchers for services like personal care (assisting with
activities like bathing and getting dressed) and
home-delivered meals. As of 2023, 15 personal care
service providers, seven home-delivered meal providers,
and seven hospitals participate in the program.
Prior to Hospital2Home, AAA7 operated a case management
program which offered ongoing personal care and
home-delivered meals with Senior Community Services State
Block grant funds. Unfortunately, this program had only
one case manager assigned to a large service area, which
created long waitlists for services. Through the use of
vouchers and referrals, Hospital2Home is able to use this
same funding source to reach the same population without
Hospital discharge planners and/or social workers
identify recently admitted patients age 60 or older who
are not currently on Medicaid and who have an elevated
risk of hospital readmission. Risk factors include:
Having limited access to or no caregivers
Being 75 years or older
Taking 6+ medications
Living with more than one chronic condition
Having stayed in the hospital
The program offers redeemable service vouchers for
home-delivered meals and personal care. Patients eligible
for home-delivered meals are those who are unable to
prepare their own meals and/or don't have a caregiver who
prepares their meals. Patients eligible for personal care
are those who need assistance with at least two
activities of daily living (ADLs) such as bathing,
getting dressed, and eating.
In addition, patients can speak with an AAA7 options
counselor about long-term care services and supports. The
options counselor also helps patients understand their
medications and discharge instructions and teaches them
how to access any needed transportation and medical care.
This counselor stays in touch with the patient for up to
three months after hospital discharge.
In the program's first year, Hospital2Home served twice
as many patients as the previous case management program
and used 27% less funding. In 2020 and 2021, fewer
participants were served, related to the pandemic and
decreased hospital stays for routine or scheduled
procedures. However, many participants who were
discharged after being hospitalized for COVID-19 were
served by the program, initially through the
home-delivered meals and later - as homecare agencies
developed COVID guidelines - through personal care
services. Beginning in April 2022, more normal operations
have resumed in the rural area. In each of the six years
the program has been in operation, between 85-90% of
participants avoided readmission in the first two months
In addition, the program has seen the following outcomes:
91% of participants rated services as excellent
93% rated the options counselor's service as
85% reported that the options counselor educated them
on available community resources
80% reported that the services helped their recovery
59% reported that the services
helped their caregivers
In July 2018, the program received an Aging
Innovations and Achievement Award from the National
Association of Area Agencies on Aging. Also in 2018, AAA7
awarded their annual Partnership Award to the local
hospitals and providers who assisted with the
One initial challenge was developing a system for
confidential information exchange between AAA7 and
hospital staff, along with a shared understanding of
program eligibility. Additionally, contracting with
service providers required educating them on how they
could benefit from providing such short-term services.
A statewide direct care workforce shortage continues to
affect service availability in some counties in the AAA7
service area. One strategy for overcoming this issue has
been to increase rates for service providers. It is not
clear at this time if this strategy alone will increase
provider availability and retention.
Area Agencies on Aging as well as other social service
agencies can reduce costs and more effectively serve
older adults with this program model. Program
coordinators offer the following advice to implement a
Establish partnerships with the hospitals and
provider agencies during the planning process.
Develop a system to measure your results.
Hire experienced staff: The options counselor
providing resource information and problem-solving after
hospital discharge is essential to the success of the
Program referrals will continue to grow in rural
areas with few resources and by word of mouth. After a
few years, Hospital2Home became a "standard service"
offered by many area hospitals.
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.