Isley Goulart (left) and Margarida Holmes are Community Care Coordinators for a Home to Hospital program that Somerville-Cambridge Elder Services provides in partnership with Cambridge Health Alliance.

By Nathan Lamb

A hospital to home program that helps patients avoid unnecessary readmissions is set to expand in 2017.

Launched in 2012, the Hospital to Home program is a partnership between Somerville-Cambridge Elder Services (SCES), Mystic Valley Elder Services, and the Cambridge Health Alliance (CHA). Originally funded by a Medicare grant, the collaboration was so successful that the organizations decided to continue the collaboration past the grant’s expiration date, earlier this year.

“We are confident that the Hospital to Home program will continue to meet the needs of CHA’s most vulnerable patients as they navigate transitions from acute and sub-acute care settings back to primary care,” said Eleni Carr, Senior Director of Care Integration at CHA.

Most patients enrolled in the program have complex medical histories or are frequent users of the emergency room. Helping patients avoid common pitfalls is key to the program, and SCES Community Care Providers coordinate with CHA staff to reduce the chances of readmission by providing home visits, arranging in-home services, and offering other supports for eligible patients.

The new phase of this program aligns SCES Community Care Coordinators Margarida Holmes and Isley Goulart with CHA’s complex care teams to meet the needs of patients discharged from CHA hospitals and certain skilled nursing facilities.

Holmes said the evolving partnership allows for greater flexibility in meeting patient needs, noting that complex care teams will be able to support patients who need ongoing care management past the 30-day post-discharge period that was stipulated under the Medicare grant.

“Through our new partnership, we’re able to see not only patients who have Medicare, but also those who have other insurances and meet our criteria,” said Holmes. “This allows us to see high-risk patients on a much broader scale, without limiting our services to one group of patients.”

Known as Community-based Care Transitions, the original SCES and CHA Hospital to Home collaboration was part of a larger initiative that included Mystic Valley Elder Services and local visiting nurse associations.

SCES is a non-profit agency that supports the independence and wellbeing of older people in Somerville and Cambridge. For more information, visit eldercare.org, follow us on Facebook and Twitter, or contact the SCES Aging Information Center at 617-628-2601 for free advice and guidance.