Need: To prevent readmissions and improve the recovery process for older adults in rural southern Ohio.
Intervention: Hospital2Home identifies high-risk individuals and provides vouchers for services like personal care and home-delivered meals.
Results: In the five years the program has been in operation, consistently 90% of participants have not readmitted to the hospital 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've been discharged
from a hospital. Limited social contacts and fewer
available caregivers also place older adults at risk
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. Social service providers and seven
hospitals participate in the program.
Prior to Hospital2Home, the AAA7 operated an in-home case
managed program offering ongoing personal care and
home-delivered meals with Senior Community Services State
Block grant funds. Unfortunately, this program only had
one case manager who had to cover a large service area,
which created long waitlists for services. Hospital2Home
is able to use this same funding source to reach
higher-risk individuals without a waitlist.
Hospital discharge planners and/or social workers
identify recently admitted patients 60 or older who are
not currently on Medicaid and who have a high risk of
being readmitted to the hospital. 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 options. 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 Hospital2Home's first year, it served twice as many
patients as the previous case managed 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 able to be helped
from the program, initially through the home-delivered
meals and as homecare agencies developed guidelines for
care in the home with the personal care services.
Beginning in April 2022, more normal operations have
resumed in the rural area. The program has consistently
averaged an 86.5%-90% of participants who did not readmit
to the hospital since it began in 2017.
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. The AAA7 awarded
the local hospitals and providers with Partnership of the
Initial barriers included getting the hospitals to only
refer the high-risk eligible individuals and working with
them on a system for confidential information exchange
between the hospital and the AAA7. Additionally,
contracting with providers for the services required
educating them on what they would gain for providing such
short-term services. There is also a statewide direct
care workforce shortage, which can affect recruitment
The current national workforce shortage trend is
affecting the rural area and the statewide direct care
workforce shortage has escalated in the rural area,
bringing challenges to providing personal care services
in some counties served in the AAA7 area. One way to try
to overcome this issue has been to offer higher rates for
the service. It is not clear at this time if this
strategy will yield better results for finding and
keeping providers for personal care services. The program
remains open and is serving participants.
Area Agencies on Aging as well as other social service
agencies can utilize smaller budgets to effectively serve
older adults in the community with this program. Program
coordinators offer the following advice to implement a
Develop partnerships with the hospitals and provider
agencies during the planning process.
Include a system to measure your results.
Hire well-experienced staff: The options counselor
providing resource information and problem-solving
post-hospital discharge is essential to the success of
the reduction in readmissions.
The program referrals will continue to grow in rural
areas with few resources and by word of mouth. The
program has become a "standard service" offered by many
hospitals after five years.
Vicky Abdella, RN, Director of Community Services
Area Agency on Aging District 7, Inc.
800.582.7277, Ext. 22254 firstname.lastname@example.org
Aging and aging-related services
Home and community-based services
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.