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At Tufts Medicine’s MelroseWakefield Hospital in Melrose, Mass., discharge planners rarely struggled to find the community services an older patient needed to go home safely. The harder part was getting the patient to say yes.
That distinction sits behind a new round of state funding aimed at one of Massachusetts hospitals’ most persistent capacity problems. The Massachusetts Health Policy Commission’s Transitions from Acute Care to Post Acute Care Task Force found that an average of 2,000 patients a day remain hospitalized statewide despite being medically ready for discharge, a bottleneck that drives up lengths of stay and emergency department boarding.
The Massachusetts Health Policy Commission this year awarded $1.38 million to seven acute care hospitals through its Promoting Appropriate Transitions to Home program, known as PATHways, to help patients go directly home instead of to a skilled nursing facility or other institutional setting. The money funds partnerships between hospitals and Aging Services Access Points, community organizations that connect residents 60 and older with home care, meals, transportation and other support.
MelroseWakefield Hospital received $124,700 of the total. Boston Medical Center, Berkshire Medical Center in Pittsfield, Mass., Holyoke (Mass.) Medical Center, Lowell (Mass.) General Hospital, Southcoast Health’s St. Luke’s Hospital in New Bedford, Mass., and UMass Memorial Health’s HealthAlliance-Clinton Hospital (Leominster, Mass.) also received awards, ranging from $124,700 to $210,000.
For MelroseWakefield and its longtime partner, Mystic Valley Aging Services (based in Malden, Mass.), the funding restores a capability they say already worked, once they figured out what was breaking down. Referrals from the hospital to Mystic Valley were never the issue, Lisa Jimenez, director of clinical services at Mystic Valley Aging Services, told Becker’s. The problem showed up after the paperwork was done.
“After the referrals went through, patients were hesitant to meet with us because it was an entity that they didn’t know,” Ms. Jimenez said. “It was a stranger. They couldn’t put a face to a name.”
The fix was proximity. When a Mystic Valley liaison worked inside the hospital and was introduced directly by a nurse or social worker the patient already knew, sometimes brought right into the patient’s room, acceptance changed, said Ms. Jimenez and Christopher Mauro, director of social work and case management at MelroseWakefield Hospital.
“I trust this nurse case manager. I trust this social worker. They’re bringing this Mystic Valley person to me, so now I can trust this Mystic Valley person,” Ms. Jimenez said. “I’ll let you come to my home when I leave. I’ll let you put in services.”
Having a liaison embedded in daily rounds and team meetings changes how early Mr. Mauro’s team can identify who needs support, and keeps the relationship intact across a patient’s next hospital stay, he said.
“The majority of our patients do wind up going home with some measure of services, a visiting nurse agency or services that groups like Lisa’s group provide, really direct in-home care,” Mr. Mauro said. “We see a lot of elders return to the hospital repeatedly, and it can take a few times to really figure out what the secret sauce is to keep people healthy and well at home. Having that continuity with elder services is really going to allow us to do that.”
This isn’t MelroseWakefield’s first attempt at the model. Mystic Valley first partnered with Mr. Mauro’s team in July 2023 using American Rescue Plan Act funding, with the aging services agency, rather than the hospital, holding the grant. When that money ran out, Mystic Valley tried a scaled-down version on its own, cutting the liaison to part time.
“It didn’t work,” Ms. Jimenez said. “We really needed that full-time embedded staff person who’s at the hospital every day making these connections. Without this funding, we’re not able to do that.”
The earlier partnership’s value carried into later admissions, too, Ms. Jimenez said. When a patient with a chronic condition returned to the hospital, an already-connected service made Mr. Mauro’s team more comfortable discharging them again, since home-delivered meals and safety check-ins were already in place.
The same logic underlies the other PATHways awards. At St. Luke’s Hospital, the funding will pay for a full-time liaison from Coastline Elderly Services (based in New Bedford, Mass.), starting next year, embedded on the hospital’s discharge planning team, said Jessica Magalhaes, director of telehealth and transitional care management at Southcoast Health.
“Our clinical teams work hard to put the right support in place to allow patients to return home quickly, but connecting a patient to home care, meals and transportation often takes specialized knowledge,” she told Becker’s.
At HealthAlliance-Clinton Hospital, which operates campuses in Clinton, Fitchburg and Leominster, Mass., the funding will launch a hospital-to-home partnership for the first time. The hospital plans a planning period of up to six months, followed by 24 months of implementation, with a goal of keeping the readmission rate for participating patients below 10%.
“Through the PATHways program, we’re strengthening connections to community resources that support recovery, reduce readmission risk and help patients stay healthy,” Joseph Tennyson, MD, chief medical officer at HealthAlliance-Clinton Hospital, told Becker’s.
For Ms. Jimenez, the risk that grant funding runs dry remains real.
“I just hope that we can prove the value of having these programs, because it really is immeasurable,” she said. “It keeps people out of institutionalization.”
The post Massachusetts hospitals get $1.38M to move stuck patients home faster appeared first on Becker’s Hospital Review | Healthcare News & Analysis.
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