Key partners:

• Nevada Senior Services – a No Wrong Door partner in Las Vegas, Nevada
• Valley Health System – an integrated system of care in Las Vegas and Southern Nevada comprised of six acute care hospitals, physician practices and a variety of outpatient services
• Clark County Social Service – provides a wide range of social services and health care services to residents of Clark County
• Cognitive Solutions – a consultation firm that supports the program development of community-based organizations focused on dementia and care transitions
• Comagine Health, formerly HealthInsight Nevada – quality improvement organization
• University of Nevada Reno – program evaluator 

Nevada Senior Services (NSS), a No Wrong Door partner in Las Vegas, launched the Hospital2Home’s (H2H) Dementia Capable Care Transitions program to address challenges that individuals living with Alzheimer’s disease, related dementias, and chronic conditions, and their care partners experience in receiving inpatient healthcare and related community-based care transition services during and after a hospital stay.  

Program Overview

H2H Care Transitions is designed to aid and support adults with memory loss or those dealing with the effects of COVID-19 and their caregivers, in making a smooth transition from hospital to home. A dedicated team works directly with professionals in the community while providing caregivers with much-needed support and resources.

This transitional care program is delivered by licensed social workers who provide care coordination in-person, virtually, and via telephone. H2H offers immediate response, crisis intervention, and respite coaching for each family. Through H2H, individuals receive person-centered plans that track changes in symptoms, comorbidities, behavioral and psychological symptoms, caregiver support, and education. Following the 30-day care transitions program, post-care transition services are provided by a care transitions specialist to continue care that is tailored to individual needs. H2H offers ongoing dementia capable education programs and seminars for hospital staff and caregivers to gain knowledge and provide informed support. 

They distribute a marketing flyer and referrals come via their website’s downloadable form or QR code. Referrals are also received from hospital care management, state and county social workers, first responders, hospitals, physicians, and other community-based organizations.

Funding Sources

H2H began with an Alzheimer’s and Dementia Programs Initiative (ADPI) grant from the Administration for Community Living in 2018. In 2020, during the COVID-19 pandemic, NSS broadened the scope of the program and leveraged COVID relief grants and other funding sources, including an Older Americans Act grant from Nevada Aging and Disability Services Division and contracts with employers, managed care plans, and Clark County Human Services.

With this additional funding, NSS grew H2H in collaboration with Clark County Social Services and Valley Health System. They expanded from just individuals living with dementia to any individual with a complex case. The program development team included Cognitive Solutions and Comagine Health Nevada (HealthInsight).

Key Outcomes

H2H tracks readmission rates, caregiver depression, self-rated health, patient engagement, and patient-caregiver interactions. H2H achieved a readmission rate of less than one percent and showed decreases in caregiver depression, and increases in self-rated health, patient engagement, and patient-caregiver interactions. Collecting this data created a path to sustainability and helped point the way to expand target populations, develop meaningful metrics, and identify potential new partners.