Finding Your Way Home – Hospital to Home Program

by Gabe Taylor

Mandi Strantz, Care Transition Coordinator for The Independence Center, works tirelessly to keep people with disabilities, who have landed in the hospital, from unnecessarily being transitioned to nursing homes. There’s a disturbing trend when people with complex cases are hospitalized, and aren’t recovering quickly enough. They are often transferred to nursing homes, where many patients find themselves trapped. After not being in their home for an extended period of time, bills can go unpaid, life moves on, and they lose the ability to move back home. Even if they are still able to live a life of independence, many individuals don’t have the necessary network or resources in place to escape the clutches of institutional living. When speaking to Strantz about this epidemic, she tells me “That’s how individuals get stuck there, and have a very difficult time getting back home, and end up losing everything they have. So we want to have a paradigm shift in thinking, to say let’s get people home – it’s better for them as a person, it’s better for their health, and it’s cheaper.”

The Independence Center’s Hospital to Home Transitions (H2H) program is a pilot program that began in March of 2018. The program was started after two years of discussions and planning on how to best tackle the issue of unnecessary nursing home placements. H2H provides services such as meals in the home, transportation, setting up home health care, setting up homemaking services such as housekeeping and grocery pickup, procuring and setting up durable medical equipment, and helping with medication delivery and funding. By providing these types of services, patients receive the supports they need to get back in their home to focus on their recovery without being institutionalized.

One of the most puzzling aspects of the unnecessary transitioning of patients to nursing homes, is the astronomical cost. According to the U.S. Department of Health and Human Services, in 2017, the average cost of a private room in a U.S. nursing home was $7,698 per month, or roughly $92,000 per year. By transitioning people back into their homes, it maintains the patient’s independence and saves a fortune for everyone involved – from the hospital, to the insurance company, to Medicaid. When speaking about the cost, Mandi tells me that between the eleven individuals the H2H program has helped transition home, the cost has been significantly lower.

Darioun’s Transition Story

One patient who has benefited from the H2H program is Darioun McCune. After being shot in the abdomen, Darioun faced numerous surgeries and an extremely complex and extended recovery. Several months after being hospitalized, Darioun was released, but was quickly readmitted with pneumonia. Upon his second discharge, the H2H program stepped in. Many cases with this level of complexity would have resulted in the patient being transferred to a nursing home, but with the persistence of his Aunt Sonya and the H2H program, Darioun was able to find the supports he needed to recover at home. Sonya was even able to become Darioun’s caregiver through The IC’s Home Health department. The IC’s Benefits department was able to help Darioun get the benefits he needed to pay for his care, and to arrange transportation to and from high school, where Darioun is working to graduate and go on to college. When asked about his experience with The IC’s H2H program, Darioun says he’s very thankful, going on to say “I got a chance to meet so many people at The IC. They have helped me understand that everybody with disabilities, aren’t helpless”. Without the intervention of the H2H program, it’s hard to say where Darioun would be in his recovery, but what is certain, is that H2H has helped to make the transition easier.

The H2H pilot program was launched in partnership with UC Health – Memorial Hospital in Colorado Springs with help from Joseph Foecking, Director of Rehabilitation at Memorial Health System, and a Board Member here at The Independence Center. So far the program has been an overwhelming success, beating initial goals for the number of patients transitioned home, and for the small number of patients readmitted to the hospital. The results of the pilot program are clear, by providing needed supports for patients recovering in their homes, everyone wins.

The future of the H2H program looks bright, as the pilot program was recently extended for another six months. Going forward, we’re hopeful other local hospitals will recognize the value of the program and adopt this more humane and cost effective philosophy. To learn more about the H2H program, visit The IC on the web at , or by telephone at 719-471-8181.

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