Hospital to Home Transition Support


Too often, older adults and adults living with disabilities are released from the hospital with no support, no groceries, and no one checking in on them to ensure their safety, all of which contribute to the high rehospitalization rates.  We aim to end that cycle.

Mystic Valley Elder Services has teamed up with Somerville-Cambridge Elder Services, Hallmark Health System, and Cambridge Health Alliance to ensure that you have the full supports you need to leave the hospital, return home safely, maintain your health, and avoid returning to the hospital. We’re calling this program the Mystic Valley Basin Care Transitions Collaborative.

Through the Collaborative, Medicare patients who have been admitted to the hospital for three or more days OR who have a diagnosis of heart failure or Chronic Obstructive Pulmonary Disease (COPD) will receive one-on-one support from a specially trained caseworker. The caseworker will work closely with you to make sure that you understand your prescriptions and that you have a plan to have them filled; and that you have the support you need upon returning home, either through family, friends, or one of the elder service agencies.

The caseworker will also help you make follow-up appointments with your doctors and arrange transportation, if necessary, to the medical visits. Your caseworker will check in on you at home to make sure you’ve got what you need, and will stay in touch with you for a full 30 days after you return home.

Increased nursing supports are available if you need a little extra help.

The Care Transitions Collaborative provides these services at no cost to the patient. Currently, Care Transitions Services are available to Medicare beneficiaries (including those under 65) who are served by Lawrence Memorial Hospital, Melrose Wakefield Hospital, Whidden Hospital, or Cambridge Hospital regardless of where they reside.

To find out more, call us at 781-324-7705.

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DONATE to support the programs that older adults and adults living with disabilities rely upon when returning from the hospital, such as Meals on Wheels and help obtaining medications and medical devices.

REQUEST more information about the Care Transitions Collaborative or other Mystic Valley Elder Services’s programs.

Did you have a successful transition back home with the help of the Care Transitions Collaborative? SHARE your story to inspire others!