New program helps elderly patients go home after a hospital stay
A new partnership between Cape Cod Healthcare and Elder Services of Cape Cod and the Islands will help keep more Cape Cod patients at home after hospitalization, rather than being transferred to a nursing home.
Known as the Hospital to Home Partnership Program, the statewide initiative is funded through grant money from the federal American Rescue Plan Act Home and Community-Based Services. The grants are awarded through state governors’ offices.
The program is designed to help connect patients with services that enable them to be safe and successful at home, thereby removing the need for a nursing home placement.
In March of 2023, the Healy-Driscoll Administration awarded $3 million in grant money to connect what are known as “Aging Service Access Points (ASAPs),” like Elder Services of Cape Cod and the Islands, with healthcare organizations. In June of this year, the administration expanded the program by adding an additional $1 million.
ASAPs are elder services programs across the state that provide home care services. The Hospital to Home Partnership grants are awarded to them if they create a partnership with a healthcare organization. On the Cape, Elder Services is the ASAP that received the grant in partnership with Cape Cod Healthcare (CCHC).
There are currently 24 ASAPs across Massachusetts, and nine were awarded the partnership grants in 2023. An additional six, including the new Elder Services-Cape Cod Healthcare partnership - were awarded this year.
Not only does the program free up hospital resources, it connects patients to community resources and is also what most patients prefer, said Kathleen Cole, MSN, RN, CCM, executive director of clinical resources management for CCHC.
“I think most people want to go home,” she said. “The problem is there has always been kind of a gap between some of the community services and acute care, this program will help bridge that gap”.
Liaisons at the Two Cape Hospitals
The grant money will allow the Cape ASAP to hire a liaison for Cape Cod Hospital and Falmouth Hospital, Cole said. The liaison will spend a portion of their time at the hospital working with the case management team, and a portion of their time assessing the patient in the home setting to see what their needs are.
“We’re hoping that the case management and social work team partnering with these ASAP workers will help people qualify for different programs that are available through Elder Services of Cape Cod and the Islands in a more efficient and effective manner, instead of it taking months,” Cole said.
“Then we’ll be able to bridge that gap of people who will be eligible to go home instead of a short-term rehab or other levels of care, because they will have more supportive services in the home that will make their transition more successful.”
Cole explained that part of the reason so many older patients have traditionally been unable to go home is that they need what is called “nonskilled but supportive care” to help with the activities of daily living, such as:
- Food shopping
- Nutritional support
- Housekeeping
- Laundry
- Rides to get their medications
- Rides to doctors’ appointments
- Some patients will need 24-hour care in the home
- Support for caregivers in the home
- Housing support advocacy
Elder Services of Cape Cod and the Islands has contracts with elder care programs that can provide these types of services for free or for a lower fee to these patients. The liaison will be able to help the hospitals escalate these types of services.
Part of Discharge Planning
“The hospital liaison from Elder Services will be embedded in the hospital as part of our discharge planning, and I think it will make a big difference,” Cole said. “They would be the person who is much more knowledgeable about all of the community services that aren’t the traditional ones we would use. I think it’s going to result in better homecare planning all around.”
The liaisons will work very closely with the case management team to prioritize the cases that are higher risk for readmission or higher risk for not being successful at home, Cole said. Some of the patients might be borderline patients that might have had to go to a skilled nursing facility in the past but now they will be supported in the community so they can go home.
Cole is also hoping that if these patients get the care they need in their homes, they won’t end up continuously being readmitted to the hospital.
Cape Cod Healthcare President and CEO Michael K. Lauf is an enthusiastic supporter of the program.
“This opportunity to build a strong community partnership with the team from Elder Services of Cape Cod and the Islands, and together close a care gap for our older adult patients who are able to discharge to their homes, will have a truly positive impact on our community,” he said. “With streamlined support services in place, older patients can continue their care management in the safety and comfort of their home, and we can ensure that our hospitals have capacity for those in need.”
