By Nathan Lamb

Returning home after a hospital stay can be tricky, but Somerville-Cambridge Elder Services (SCES) is expanding a program dedicated to helping older adults navigate that transition.

The move comes after SCES was included in a $3 million statewide round of grants from the Healey Administration to augment hospital-to-home partnerships between health care providers and Aging Service Access Points, such as SCES.

SCES Chief Program Officer Annie Fowler said the grant will fund dedicated hospital-to-home liaisons to help with discharge planning at the Cambridge and Everett Cambridge Health Alliance (CHA) hospitals.

“Our Hospital to Home partnership has had a great track record of success, and this grant will allow us to build on that foundation by providing a community-based-services perspective earlier in the discharge process,” said Fowler.

The SCES Hospital to Home Community Care Transitions (H2H) program was established in 2012 as part of a nationwide pilot to reduce avoidable hospital readmissions. By connecting older adults with services and providing support during their transition back home, the pilot reduced re-admissions by 30% in 2015, making it one of the top performing programs in the country.

SCES H2H currently provides three Community Care Coordinators, who provide support for CHA patients during discharge by assessing in-home needs, coordinating services, and providing follow-up support.

SCES CEO Marta Corvelo said the expansion is great news for older adults and thanked the Healey Administration for recognizing that elder services are uniquely positioned to address in-home and environmental conditions that directly impact patient outcomes.

“By helping us expand this program, the Healey Administration is supporting an innovative partnership that improves public health in our community,” said Corvelo. “We are grateful for their support and look forward to highlighting the positive impacts of this initiative.”

The two-year, $300,000 grant is a joint effort with Mystic Valley Elder Services (MVES), which will provide the designated liaison at Everett Hospital.  MVES previously collaborated with SCES on the H2H pilot project in 2012.

“We are delighted to deepen our partnership with Somerville-Cambridge Elder Services with this grant, which allows patients with multiple care needs to be discharged with additional home services,” said Eleni Carr, chief care integration officer at Cambridge Health Alliance. “With this emphasis on the pre-discharge planning for at-risk patients, we hope to reduce the need for out-of-home placement which has become exceedingly difficult in the post-pandemic environment, causing discharge delays and other systemic challenges. I am grateful for the creative collaboration that brings Mystic Valley Elder Services into this arrangement so that our planned model can be employed at both CHA Cambridge and Everett Hospitals.”

In announcing the statewide round of Hospital to Home grants, the Healey Administration said its goals are supporting successful transitions back home and easing strains on hospital capacity.  

“As hospitals continue to face strain due to workforce shortages, it is critical that we find new ways to better serve patients in their homes and communities,” said Secretary of Health and Human Services Kate Walsh. “Through these partnerships, hospitals and local ASAPs will collaborate to better meet individual patient needs in home and community-based settings, improving health outcomes and alleviating pressure on hospital resources and staff.”

Somerville-Cambridge Elder Services is a non-profit agency that supports the independence and well-being of older adults in Somerville and Cambridge. For free advice and guidance on questions of aging, caregiving or disability, contact our Aging Information Center at 617-628-2601, email info@eldercare.org, or visit our website eldercare.org.