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Transitional Care Program for Seniors

Mills-Peninsula offers inpatient hospital care to more than 7,000 seniors (65 and older), accounting for nearly half of all admissions annually. Within this group, 15 percent are re-admitted within 30 days, 25 percent within 90 days, and 31 percent within 180 days.

These statistics can be explained by the fact that many older adults experience breakdowns in care during the transition from hospital to home. This results in high rates of poor outcomes and rehospitalization. Elders with multiple medical problems, functional deficits, cognitive impairment, emotional problems, and poor general health are at particular risk during this transition. So are racial/ethnic minorities, non-English speakers, and immigrants.

The most common factors associated with these high levels of readmission include:

• Lack of care coordination among different care settings
• Social problems such as living alone, providing care to another senior or lack of financial stability
• Not being connected to available community resources
• No follow-up visit with a physician

In response to the growing need for coordinated care following hospitalization, Mills-Peninsula Hospital Foundation has established a partnership between our hospital, physicians and the local community to develop a formal continuum of care model, or Transitional Care Program, that will respond to the growing need for improved discharge planning and transitional home care services.

Specifically, the program will establish:

• A short-term intensive stabilization care model
• A long-term "Buddy Program" that monitors the ongoing care plan to sustain the patient in the community after discharge

The program will work with the senior patient to develop a plan-of-care that allows them to achieve as much independence as possible after an acute hospitalization – critical in their healthy aging journey. It will provide social work case management oversight and the short-term services (meals, housing, transportation, and in-home care workers) necessary for immediate stabilization upon discharge. Through case management, older adults will become linked to a variety of services to help them remain in their own home and successfully “age in place.”

Our ultimate goal is to design a patient-centered transitional care program for senior patients with complex medical and social needs that will integrate and coordinate services and care across the continuum, from hospital to home, and provide ongoing services to foster independence.

Learn More

We have charted a plan to make this vision a reality and now we invite you to partner with us in this endeavor. For more information about how you can support this project, please contact John Loder, president of Mills-Peninsula Hospital Foundation, at loderj@sutterhealth.org or 650-696-5958.

Make a donation to the Transitional Care Program for Seniors