LSA Blog

Building an Innovative Model for Better Transitional Care

Blog Date: 
Tuesday, September 3, 2019

By Charlotte Haberaecker, President and CEO

Older Americans comprise an especially vulnerable group after hospitalization. The millions of older adults who transition from post-acute care to their homes annually are dependent on caregivers for three to six activities of daily living once they return home. Yet in their efforts to get and stay well, too many patients and their caregivers don’t fully understand the extent of the patient’s needs in the critical time following acute care. This challenge plays a central role in an astonishing statistic: according to the Medicare Payment Advisory Commission, an estimated three-quarters of all 30-day hospital readmissions are preventable.[1]

The good news is a clear opportunity exists to view the challenge of transitional care and recuperating seniors’ needs through a new lens. Lutheran Services in America, its national network and The University of North Carolina at Chapel Hill formed a learning collaborative to better prepare older adults to successfully transition home from post-acute care facilities. The collaborative offers a model that provides transitional care services with skilled nursing professionals and expanded potential for change.

“Connect-Home” was developed by Dr. Mark Toles, an assistant professor at UNC with expertise in nursing and transitional care for older adults. The Connect-Home intervention — a process to improve the delivery of transitional care — includes a much-needed set of tools and guidelines that empower staff and family caregivers to support vulnerable older adults during their post-acute care transition times. Its important goal is to help older adults transition home to live with greater independence and a higher quality of life.

Thanks to renewed, generous financial support from The Harry and Jeanette Weinberg Foundation, Lutheran Services in America and member organizations of our national network of health and human service organizations have begun executing Connect-Home’s second phase. Under Phase 2, participating organizations will serve 275 low-income older adults transitioning out of post-acute care in Ohio, Pennsylvania, New York, and Wisconsin.

Our 12-month Phase 2 expands and builds on the 325 adults reached during Connect-Home’s Phase 1, which showed impressive – and incredibly promising – results.  Launched in 2018 in Maryland, Michigan, New Jersey, and North Carolina, participants at these first four states saw 90 percent of caregivers attending both midpoint and discharge meetings, more than 90 percent of discharged patients scheduling and confirming physician appointments, and 90 percent of patients completing follow-up calls within 72 hours after discharge. Indeed, clinical leaders who implemented Connect-Home during Phase 1 report the intervention was associated with improvement in processes and outcomes in patient care. As such, it earned accolades from staff, with one nursing leader saying that Connect-Home “helps us pull all the disciplines together.” Doing so represents a significant, unifying piece that prior to Connect-Home had been missing from the post-acute landscape.

Importantly, Phase 2 of this valuable learning collaborative will offer several hundred more seniors improved transitional care, with the expectation of also producing significantly reduced rates of hospital readmissions.

With the model continuing to expand, we are confident Connect-Home could become a model for post-acute care providers nationwide – a model so needed given our aging demographics and ever-shifting managed care climate today, in which a growing number of older Americans are battling multiple chronic conditions. Given the promising results seen from Connect-Home’s Phase 1, by doubling the size of outreach in Phase 2 to four additional sites we expect we will be able to help transform the lives of so many more underserved seniors and their caregivers.

Additional progress cannot come a moment too soon.

For further information about the Connect-Home Learning Collaborative, contact David Zauche at


[1] Van, Charlayne, and Joel Andress. Development of Potentially Preventable Readmission Measures for Post-Acute Care. Deliverable 14. The Centers for Medicare & Medicaid Services. February 2016.

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