New Hampshire: Care Transitions from Facility to Home During the COVID-19 Pandemic

Key Partners: ADRCs, hospital discharge planners, New Hampshire Care Collaborative

The Aging and Disability Resource Centers (ADRCs) in New Hampshire (called ServiceLinks) have a long history of supporting transitions from hospital and nursing facilities to the community. Prior to the pandemic, the ServiceLink in Cheshire County, and their sponsoring agency, New Hampshire Care Collaborative[1], developed a formal partnership to provide transitional discharge support for hospitalized individuals at risk for nursing facility admission referred from Cheshire Medical Center-Dartmouth Hitchcock Keene hospital. The partnership included a memorandum of understanding between the hospital and the New Hampshire Care Collaborative. This work was initially funded through federal grants and is currently sustained through ServiceLink’s operating budget. This includes revenue generated through billing by New Hampshire Care Collaborative for transitional case management as part of the Medicaid waiver program, Choices for Independence.

Before the pandemic, hospital staff would introduce the ServiceLink options counselor to the person on site at the hospital prior to discharge. Once the person discharged to a short-term nursing facility stay or directly home, the ServiceLink options counselor provided person-centered planning, short-term service coordination, including Medicaid waiver services and, in some cases, connected family members to family caregiver support services. 

Due to COVID restrictions, ServiceLink staff were not able to meet individuals in person at the hospital or nursing facilities, and home visits were limited. ServiceLink provided tablets and cell phones to hospital staff to facilitate virtual introductions between ServiceLink options counselors and hospitalized individuals. This virtual warm handoff allowed the ServiceLink options counselor to get permission from the person to follow up post discharge and it provided an opportunity for the person to begin to build a relationship. While the ServiceLink team continues to support virtual transitions, the hospital now allows options counselors to begin the process of reinstating privileges to see individuals on site. ServiceLink staff plan to be back on site on a regular schedule to connect with discharge social workers and follow up with individuals soon, as appropriate.

 


[1] The New Hampshire Care Collaborative is a 501c3 organization that houses the ServiceLinks across the state. New Hampshire Care Collaborative owns the ServiceLink contract for the Monadock region of the state.

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