Hospital to Home
Too often, after a hospital stay, seniors return home without the preparation or support they need to avoid another health crisis and another hospitalization. At Health Research for Action, we undertook comprehensive research to help prevent this downward spiral. We gathered insight not only from existing research but also through focus groups and interviews with seniors, providers, caregivers, and policymakers.
Funded by the Gordon and Betty Moore Foundation, our strategic assessment identified ways to improve hospital-to-home transitions for seniors and for their caregivers:
- Interventions to educate seniors and their caregivers
- Improved access to community resources
- Provider training to improve discharge planning and follow-up
- Systems and policy-level changes
- A national Transitional Care Leadership Summit
We are developing a model program of transitional care that can improve outcomes for the most vulnerable seniors, including those who speak little or no English, or who have no caregivers and lack the ability to advocate for themselves and navigate our complex health care system.