Connect-Home Learning Collaborative

Through two generous grants from The Harry and Jeanette Weinberg Foundation, Lutheran Services in America partners with The University of North Carolina at Chapel Hill (UNC) to scale Connect-Home, a proven model of care for older adults in rehabilitation to successfully transition home. Lutheran Services in America and University of North Carolina’s Dr. Mark Toles and his team have implemented Connect-Home at seven member organizations across the country. Connect-Home is an evidence-based transitional care model created by Dr. Toles that empowers older adults and their caregivers to manage older adults’ serious illnesses at home, improve function and prevent avoidable re-hospitalizations. In parallel to the work under this Collaborative, NIH has invested $1.9M in a R01 clinical trial of Connect-Home by Dr. Toles at UNC which will run through April 2022.

 The Connect-Home model retrains existing staff at post-acute care facilities to begin the conversation and prepare an older adult and their caregiver for a safe and successful return home at the start of the older adult’s care stay. The aims are to honor patient preference in discharge planning and to educate and empower older adults and their family caregivers to successfully manage follow-up care needed at home. By design, Connect-Home targets six key care needs to optimize patient and caregiver needs at home including: 1) home safety and level of assistance; 2) advance care planning; 3) symptom management; 4) medication reconciliation: 5) function and activity; and 6) coordination of care.



  • Lutheran Services in America Implementing Partners:
  • National Lutheran Communities & Services (Rockville, MD)
  • Samaritas (Grand Rapids, MI)
  • Lutheran Social Ministries of New Jersey (Florham Park, NJ)
  • Lutheran Services Carolina (Wilmington, NC)
  • Lutheran SeniorLife (Mars, PA)
  • Niagara Lutheran Health System (Lancaster, NY)
  • Luther Manor (Wauwatosa, WI)


Publication in Geriatric Nursing

Lutheran Services in America co-authored a study published in April 2021 by the medical journal Geriatric Nursing on the impact of our Connect-Home learning collaborative’s implementation of the innovative intervention for older adults in post-acute care.

Developed by Dr. Mark Toles at the University of North Carolina at Chapel Hill, Connect-Home empowers older adults and their caregivers to manage serious illnesses at home, improve function and prevent avoidable re-hospitalizations. The findings of this study help bolster confidence in the scalability of innovative transition care practices that retrain post-acute care workers and proactively address social determinants of health to improve the quality of care for low-income and isolated older adults.

The study, which evaluated implementation of the Connect-Home framework during the COVID-19 pandemic, found that in following the protocol, the number of follow-up physician appointments that were scheduled for older adults increased from 30 percent to 74 percent, and substantial improvements were observed in the rate staff completed discharge summaries, transmitted health records to next providers of care, and completed post-discharge follow-up calls.

The evaluation is the latest demonstration of the unique role Lutheran Services in America holds in bringing together Lutheran social ministry organizations with national partners in academia, healthcare and philanthropy to advance transformative practices that lead to better outcomes for older adults. The paper, titled “Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative,” was written by Alesia Frerichs, vice president of member engagement at Lutheran Services in America, and Dr. Mark Toles. The study was funded by The Harry and Jeanette Weinberg Foundation.

Read the study.

For more information about Connect-Home, contact Ashley Washington at