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Helping Medicare recipients avoid returning to the hospital: A Central Valley solution for the nation
senior health

When Obamacare became law in 2010, Congress also established a program to reduce hospital readmissions for Medicare beneficiaries. Though Congress referred to it as an “incentive,” in truth, it financially penalized hospitals if a Medicare recipient was readmitted within 30 days of discharge.

Since that time, the negative impact on Medicare patients is often lost in the overall goal. Far too often, once discharged from the hospital, Medicare patients are forced to wait 48 hours or more for care that will help ensure they are not readmitted. This kind of care varies from being able to access and afford their necessary daily medications, having meals available if they cannot cook or afford groceries, having access to a nurse to help them with wound or bandage changes, and making their home safe for independent recovery.

At Legacy Health Endowment (LHE), we believe it is paramount that elderly patients receive the post-hospitalization care they need.

We discovered that the 48 hours after patients are discharged are critical. This time frame is considered the make-it-or-break-it time when patients truly need help or intervention. Sadly, the government and insurance bureaucracy generally do not operate effectively or efficiently, and patients often are left to fend for themselves right after discharge

In 2019, LHE joined Covenant Care at Home to create the Bridge to Home (BTH) program across southern Stanislaus County and northern Merced County to provide immediate care coverage during those 48 hours after Medicare patients are released from the hospital. The care is free and funded through a grant from LHE. Every Medicare or Medi-Cal patient in need of home healthcare is eligible.

Bridge to Home meets patients at home on the first day of discharge and, in some cases, even provides transportation home. The program builds a bridge from the acute care hospital to the skilled services that start 24 to 48 hours later. BTH ensures clients have everything they need upon discharge and are set up to succeed.

For example, the BTH program can fill a prescription (and pay for it if patients cannot afford it). BTH provides skilled nursing and access to therapists. It also includes a Meals on Wheels program for the first 30 days at home and simple housekeeping such as laundry and meal set-up.

One of the most critical services included in BTH is transportation to and assistance for the first medical appointment post-discharge. According to Dr. Sean R. Muldoon, the Chief Medical Officer of Kindred Hospitals, seeing the doctor within 7 – 15 days post-discharge reduces rehospitalization for this fragile group by 20%.

While our target audience has been Medicare-eligible recipients most likely to need more care at home after their hospital discharge, where we find Medi-Cal patients in need, they also are covered. The typical BTH patient suffers from heart failure, COPD, pneumonia, COVID, falls with injury or multiple hospitalizations, and medically frail seniors above age 75.

As of September 2022, more than 400 local patients have received 10 free hours of private home care services immediately following their discharge from either Emanuel Medical Center or a local skilled nursing facility. Most importantly, less than 7% of the patients were readmitted to the hospital (the national average exceeds 15%).


Hospital readmissions come with a steep cost. According to the most recent data from 2015, one in five elderly patients was readmitted to the hospital within 30 days of discharge, costing Medicare some $17 billion.


The Bridge to Home program is expanding to help residents and families avoid the fear of being readmitted to a hospital or prematurely entering a nursing home. When other programs say having help at home may disqualify you from assistance, our goal is to educate retirees and their families and let them know that this program cares for the patient and the caregiver. That second part is crucial. Whether it’s seniors caring for other seniors, working parents juggling kids at home and aging parents, or other members of the community, assistance for caregivers provides security in a crucial time of patient care.

LHE believes in using charitable dollars to help ensure that elderly and disabled community members who need help can access care without fearing the cost. If you cannot afford the necessary services, the care is still provided.

Our plan is simple: caring for every aging resident across the LHE 19 zip codes who needs help regardless of income or other healthcare barriers. The goal is to help every senior citizen thrive at home, not in a nursing home or other facility unless they choose to be there.

If you are interested in the Bridge to Home program, call (209) 250-5200 or my office at (209) 250-2315.

— Jeffrey Lewis is the President and CEO of Legacy Health Endowment. The views expressed are his own.