Rosemarie, a retired paralegal, is happy to be living independently in her own home following an unexpectedly challenging stretch that started with a double hip replacement. The resulting weakness and loss of mobility led to multiple hospital admissions and eventually a recommendation that she consider assisted living. In April, during Rosemarie’s stay at Newton Wellesley Hospital, Maggie Gosen, Springwell’s Hospital to Home Liaison, knocked on her door.

Last year, the MA Executive Office of Health and Human Services awarded Springwell and Newton Wellesley Hospital a two-year grant to pilot a Hospital to Home partnership. This unique and innovative program embeds a Springwell staff member on-site at the hospital to assist older adults with discharging and transitioning home. Typically, when patients are preparing for discharge, they are simply provided with contact information to set up support services like meal provision, medical transportation, and caregiver education. For older patients who live alone and lack a strong support network, this approach often results in referrals for these services being dropped. This can lead to a cycle of readmission, which the Hospital to Home program mitigates through the one-on-one, personalized approach of a liaison who provides support and coordination during the key transitional period following discharge to ensure that non-medical services start and in-home care needs are met.

Rosemarie was initially skeptical of any referrals for in-home supports. Still, she met with Maggie a few times before her discharge, and Maggie explained to her what kind of services might be possible. When Rosemarie was re-admitted two weeks later, she was happy to see a familiar, trusted person and was eager to work with Maggie to create a plan that would address some of the challenges of living independently with her current mobility issues.

According to Rosemarie, what Maggie did was not only coordinate all the different people who needed to be involved and services that needed to be set up, but she also listened to and prioritized Rosemarie’s plan for what she wanted to have happen. Maggie also provided an important link and sense of continuity for Rosemarie, meeting with her both in the hospital and then on her first day at home, establishing a bridge to her new home-based services.

Today, Rosemarie is successfully living at home and managing her ongoing health care needs without unnecessary trips to the emergency room. She has a dedicated Springwell Care Manager and the support she needs to live on her own with the in-home services that are right for her.

This holiday season, please consider donating close to home in order to support Springwell’s efforts to help older adults and caregivers to get the help they need to live and age in the place they love best: home.