Mystic Valley Elder Services (MVES) is honored to be one of nine nonprofit organizations awarded funds to through the state’s new Hospital to Home Partnership Program. This new pilot initiative supports partnerships between hospitals and Aging Services Access Points (ASAPs). By strengthening communication and coordination with community providers, MVES and its partners will promote institutional diversion and increase discharge rates from hospital to home.
The Hospital to Home initiative was launched by the Massachusetts Executive Office of Health and Human Services (EOHHS) using three million in federal dollars made available through the American Rescue Plan Act (ARPA). MVES will participate in two of the pilot programs that received $300,000 for two years.
“As hospitals continue to face strain due to workforce shortages, it is critical that we find new ways to better serve patients in their homes and communities,” said EOHHS Secretary Kate Walsh. “Through these partnerships, hospitals and local ASAPs will collaborate to better meet individual patient needs in home and community-based settings, improving health outcomes and alleviating pressure on hospital resources and staff.”
MVES will serve as the lead entity for the Hospital to Home Pilot in partnership with AgeSpan and Tufts MelroseWakefield Hospital/Lowell General Hospital. MVES will also serve as a partner on the Hospital to Home Pilot led by Somerville-Cambridge Elder Services, which includes the Cambridge and Everett hospitals of Cambridge Health Alliance (CHA).
Funding through both pilots will enable MVES to hire two dedicated hospital-to-home liaisons who will be embedded at Tufts MelroseWakefield and CHA Everett hospitals. Working in close communication and partnership with hospital discharge planning staff will enable MVES hospital-to-home liaisons to understand the immediate needs of patients and draw upon a deep range of knowledge to ensure safe, secure and quick transitions home. MVES hospital-to-home liaison staff will also remain in regular contact with the patient post-discharge to support transition and address any additional needs.
“Together, we will make a positive impact on the ability of older adults to seamlessly transition from inpatient hospital stays to safe discharges back home,” said MVES Assistant Nurse Manager Lisa Jimenez. “Our staff are well trained to respond quickly to a wide variety of urgent community needs such as: coordinating and monitoring the provision of highly skilled personal and home care assistance to be available upon patient discharge; arranging for next-day delivery of culturally appropriate Meals on Wheels; restocking the person’s home with essential food items and toiletries; scheduling transportation to follow-up doctor appointments and more.”
“MVES has a long history of working collaboratively with Tufts MelroseWakefield and CHA Everett hospitals to connect patients transitioning home with community-based services and supports they need to remain in the community,” explained MVES CEO Lisa Gurgone. “We are excited about the opportunity to work with our hospital and ASAP partners to reduce the rates of transitions to nursing facilities in our service area. We are grateful to the Commonwealth for funding this important innovation and empowering us to make a meaningful increase in hospital-to-home transitions.”
About Mystic Valley Elder Services: Since 1975, MVES has partnered with individuals and caregivers across the Mystic Valley region to ensure that adults age 60 and older and people with disabilities have the support they need to live independently and with dignity. Located in Malden, Mass., the nonprofit agency provides information, care and resources to residents of Chelsea, Everett, Malden, Medford, Melrose, North Reading, Reading, Revere, Stoneham, Wakefield and Winthrop. Services are either free or are offered at a sliding fee scale, and they are funded in part by the Massachusetts Executive Office of Elder Affairs.
Through direct services, care coordination and a network of business partners, the MVES team helps individuals access the supports they need to age in place throughout the community. Services include information and referral, options counseling, case management, home care, elder protective services, health insurance benefits counseling, caregiver supports, transportation, Meals on Wheels and more. For more information, please call 781-324-7705 or visit www.mves.org.