Improving care transitions for older adults
Care management & redesign Strengthening ecosystems of care Quality improvement
In August 2019, Jewish Association Serving the Aging (JASA), a community-based organization, partnered with Healthfirst, a health insurer, to leverage their strengths and data-sharing capacities to deliver a community-based care transitions intervention supporting older adults with complex health and social needs. The intervention addresses the social determinants of health, prevents avoidable hospital admissions, and enables stable home-based functioning through home visits and linkages to community resources and mental health services. Preliminary results from an evaluation led by Healthfirst demonstrate that members who received the care transitions intervention had a 26% lower readmission rate than those who did not.
In this webinar session, we welcomed Arielle Basch and Karen Schmalbach of JASA and Rashi Kumar of Healthfirst to share takeaways from their partnership, more information about the collaborative program they created, and the impact it has on reducing avoidable hospital readmissions and closing gaps in care.
- Arielle Basch, Senior Director of Health Services and Business Development, JASA
- Rashi Kumar, Director, Healthfirst Partnerships – Strategies for Medical Outcomes, Healthfirst
- Karen Schmalbach, Community Health Worker/Care Transitions Trainer, JASA