Hospital to Home: A Proven Pathway to Safer, Faster Discharges in Massachusetts

A Statewide Challenge With a Human Cost

Massachusetts hospitals are caring for hundreds of patients who no longer need acute care — but have nowhere safe to go next. According to the Massachusetts Health & Hospital Association, nearly one in seven medical-surgical beds is occupied by a patient who should already be discharged. This bottleneck contributes to more than $400 million annually in unpaid care and strains clinical teams across the Commonwealth.

The situation is intensified by a shrinking nursing home sector. Since July 2021, Massachusetts has seen the closure of multiple nursing homes, with more closures expected. This leaves clinicians with fewer placement options and families struggling to find support. In this environment, the need for reliable, community-based alternatives has never been clearer.

A Simple Idea With Big Impact

The Hospital to Home (H2H) Partnership Program, launched by the Executive Office of Health and Human Services (EOHHS) in 2023, is designed to meet this challenge. H2H is a grant-funded initiative that embeds trained Aging Services Access Point (ASAP) staff directly in hospitals. These liaisons work side-by-side with care managers, nurses, and discharge teams to:

• Identify patients who can safely return home rather than enter a nursing facility,
• Develop individualized home- and community-based service (HCBS) plans,
• Arrange supports such as homemaking, home health aides, meals, medication systems, and personal emergency response devices,
• Reduce avoidable nursing home placements, and
• Shorten unnecessary hospital stays.

The program is open to people of all ages and is insurance-agnostic. Many participants have complex medical needs, behavioral health conditions, substance use histories, dementia, or housing instability. The majority are age 60 and older, but there are no age restrictions for referral.

The impact has been immediate. In just the first nine months, more than 1,800 referrals were made through the H2H program, underscoring both the level of need and the effectiveness of having hospital-embedded community partners.

Who Benefits From the H2H Partnership?

Patients and Families

Most H2H referrals involve individuals with multiple medical or behavioral health challenges, limited caregiving support, or unstable housing. Many live alone or rely on informal caregivers who may themselves need help. By coordinating home care, meals, safety technology, and case management, the program helps people return home safely and avoid unnecessary institutionalization.

Hospitals

For hospitals, H2H provides a practical answer to discharge delays. By removing barriers and connecting patients with ASAPs and home- and community-based services, the program:

• Frees up acute care beds for patients who truly need hospital-level care,
• Reduces the financial burden of extended, unreimbursed stays, and
• Improves workflow and morale for care managers, nurses, and social workers.

Communities

At the community level, H2H strengthens local aging services networks and helps residents remain connected to their neighborhoods, faith communities, and natural supports. It also reduces pressure on long-term care facilities by supporting people to remain at home with the right mix of services.

What the Program Looks Like in Real Life

The H2H fact sheet includes several real-world examples that illustrate the depth of need and the power of the model.

Holyoke Medical Center & Access Care Partners

Mary, a 72-year-old woman with Alzheimer’s disease, anxiety, major depressive disorder, and schizophrenia, had seven hospital admissions in one year due to behavioral health issues. Each time a nursing home placement was arranged, she and her husband chose to return home, leaving the hospital team in a difficult position.

Through H2H, an embedded liaison met with Mary, her spouse, and the hospital team to develop a plan to make home a safer option. The discharge plan included homemaker services, a personal emergency response system, a medication dispensing unit, home-delivered meals, and ongoing psychiatric follow-up. Since that coordinated discharge, Mary has remained at home with support and has not returned to the hospital.

Beth Israel Deaconess Plymouth & Old Colony Elder Services

A 95-year-old woman living alone was admitted with confusion and found to have a new diagnosis of Alzheimer’s dementia with psychotic disturbance, along with multiple chronic medical conditions. She was increasingly frail and at high risk for nursing home placement.

With the help of the H2H liaison, homemaker services for cleaning and meal preparation were put in place immediately, followed by the addition of a home health aide, a personal emergency response system, and home-delivered meals. She was enrolled in the Enhanced Community Options Program (ECOP), designed for frail older adults at risk of nursing home placement. With these supports, she has remained safely independent at home without further hospital readmissions.

Melrose-Wakefield Hospital & Mystic Valley Elder Services

A 61-year-old man experiencing homelessness was admitted with uncontrolled diabetes, hypertension, and ketoacidosis. He had been living in his truck after a layoff and eviction, with no way to pay for gas, medication co-pays, or stable food and hygiene.

The H2H liaison scheduled a follow-up visit at Mystic Valley Elder Services, helped him access unemployment benefits, located his insurance information so prescriptions could be filled quickly, and secured emergency funding for gas and medication co-pays. Food and toiletries were supplied from an agency pantry.

To address his lack of access to showers and social connection, the liaison obtained temporary funding for a YMCA membership, referred him to a local warming center, and provided a list of rooming house options. After 30 days, he transitioned into the agency’s ANCHOR program for intensive care management. He has since started receiving unemployment, found a job, is managing his diabetes, and continues to pursue permanent housing.

Why the Program Needs to Be Codified

The current grant funding for the Hospital to Home Partnership Program is scheduled to end in March 2025. Without legislative action, hospitals, ASAPs, and the people they serve could lose a highly effective discharge and stabilization resource just as demand continues to grow.

Two bills before the Massachusetts Legislature seek to make H2H permanent:

• S.495 – An Act to Codify the Hospital to Home Partnership Program
• H.780 – An Act Establishing the Hospital to Home Partnership Program

Codifying H2H would secure ongoing support for the existing hospital–ASAP partnerships and allow the program to expand to additional sites in future years.

A Smarter Way Forward for Massachusetts

The Hospital to Home Partnership Program offers a humane, cost-effective approach that aligns with what individuals overwhelmingly want: to remain safely at home. By strengthening collaboration between hospitals and aging service organizations, H2H:

• Supports high-risk patients with the right care at the right time,
• Relieves pressure on hospitals and payors,
• Reduces unnecessary institutional care, and
• Promotes independence, dignity, and community-based living.

As Massachusetts continues to face discharge barriers and post-acute care shortages, the Hospital to Home Partnership Program stands out as a critical part of the solution — for hospitals, for families, and most of all, for the individuals whose health and independence are at stake.