- 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 four years the program has been in operation, 86.5% 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 post-hospital.
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. The program remains one of the few hospital transition programs in the region.
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:
- Living alone
- Having limited access to or no caregivers
- Being 75 years or older
- Taking 6+ medications
- Living with more than one chronic condition
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. Over a three-month period that first year, 88 patients (89% of the total served in that three-month period) were not readmitted. In 2018, 91% of patients were not readmitted. In 2019, 87% were not readmitted. In 2020, fewer participants were served and 80% did not readmit to the hospital. The program has consistently averaged an 86.5% 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 excellent
- 85% reported that the options counselor educated them on available community resources
- 80% reported that the services helped their recovery process
In July 2018, the program received an Aging Achievement Award from the National Association of Area Agencies on Aging. The AAA7 awarded the local hospitals and providers with Partnership of the Year.
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 efforts.
The year 2020 was a difficult year with the COVID-19 pandemic. For a majority of the year, people were not hospitalized unless it was related to a COVID-19 infection and home care services were not accepted by participants or offered by many agencies due to the pandemic. The direct care workforce issues also became more prevalent. In the second quarter of 2021, some of the issues have begun to resolve with hospitalizations and the workforce. However, the program has remained open and serving participants during the pandemic.
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 successful program:
- 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 four years.
Contact InformationVicky Abdella, RN, Director of Community Services
Area Agency on Aging District 7, Inc.
800.582.7277, Ext. 22254
Aging and aging-related services
Home and community-based services
May 21, 2018
Date updated or reviewed
April 28, 2021
Suggested citation: Rural Health Information Hub, 2021. Hospital2Home [online]. Rural Health Information Hub. Available at: https://www.ruralhealthinfo.org/project-examples/1010 [Accessed 2 August 2021]
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.