The Caring Beyond Healthcare (CBH) Pilot Project was developed to reduce hospital readmissions and promote well-being of vulnerable older adults with complex medical and social needs upon hospital discharge. A primary goal of CBH was to strengthen community collaborations between hospitals and aging support services. In partnership, a hospital and Area Agency on Aging and Disabilities (AAAD) identified dual-eligible hospital patients (i.e., those who qualify for both Medicare and Medicaid) to participate in the pilot. A screening tool was developed to identify specific social needs that could be met by AAAD community-based support services to improve overall health. Over a one-year period, 225 screenings were completed, with 116 patients (mean age = 65) identified as having one or more social need. An in-depth sub-analysis of 38 patients (mean age = 62) who were referred and connected to AAAD services revealed a decline in healthcare utilization. Specifically, a decrease in 30-day readmissions by 67%, decrease in 6-month readmissions by 64%, and reduction in ER visits by 56%. Post-hoc return-on-investment analyses also estimated hospital savings at $274,000 from this reduction in healthcare utilization.
While the results of the pilot highlighted the potential success of CBH to reduce readmissions and reduce costs, the pilot also revealed strengths and challenges of organizational partnerships to provide successful community-based case management in addressing social determinants of health and supporting aging in place. In the pursuit of identifying creative and effective ways to connect vulnerable patient populations to services and supports, all community partners articulated various lessons learned during program evaluation. This included communicating the importance of cross-sectoral partnerships to taxpayers/society, the importance of mutually beneficial partnerships with buy-in at all levels of leadership, and developing sustainable practices that help reach more at-risk patients and expand the scope of the intervention.