Berkshire Health System (BHS) has been awarded $210,000 in funding through the Massachusetts Health Policy Commission’s Prompting Appropriate Transitions to Home (PATHways) program. The initiative will support Berkshire Medical Center (BMC)’s work to help adults age 60 and older leave the hospital safely and sooner by connecting them with essential non-medical support services at home.
BMC is one of the seven acute-care hospitals across Massachusetts selected for this new initiative, which is investing nearly $1.4 million statewide to strengthen hospital-to-home transitions. The program supports patients who are medically ready for discharge but need assistance arranging services before they can safely return home.
The funding will support a partnership between BMC and local aging services organizations to embed care managers within the hospital. Working alongside BMC clinical care teams, these care managers will meet with patients and families to determine what community-based resources are needed so that patients can make a safe return to home possible, including meals, medication management, transportation, and other supportive services.
Berkshire County will be among the first communities nationwide to benefit from this innovative transition-of-care model, which has drawn national attention from Modern Healthcare, a leading trade publication covering the most groundbreaking healthcare stories.
“Hospital readmissions, nursing home admissions, and overall cost to the providers also should be included to determine if the initiative is sustainable,” Darlene Rodowicz, President and CEO of Berkshire Health Systems told Modern Healthcare. “That is going to be the trick of it. If the majority of the savings is to insurers, but the cost of providing the service is with the providers, it seems like an unsustainable program. We hope the program provides some clarity on where the benefits accrue. That could help us think about how it gets funded going forward.”
“Gaps in care can often result in costly hospital readmissions,” Maureen Tuggey, Client Services Director for Elder Services of Berkshire County also told Modern Healthcare. The program is intended to improve coordination between the hospitals and aging services organizations, which help older adults and caregivers access community-based programs and support.
If successful, the program could help inform future approaches to hospital discharge planning and community-based care, supporting older adults in receiving the right care, in the right setting, at the right time.