Social Care Meets Health Care

Villages provide critically important supports and services to help their members stay healthy and out of the hospital. Health care districts, insurers and hospitals are highly motivated to reduce the number of visits, in particular “rebound” visits by the recently discharged, in order to control costs and assure Medicare reimbursements.

Sequoia Village (SV) in San Mateo County recognized an opportunity and approached Dignity Health Sequoia Hospital (DHSC) in 2016 with a modest proposal that could reduce readmission rates and ensure better health outcomes for their patients. With a small grant from DHSC, Sequoia Village enrolls recently discharged patients in a three-month introductory membership and provides transportation, minor home repairs, home safety evaluations, social events, wellness calls and friendly visits for participants. In addition, they partner with three home repair groups to perform modifications to ensure that a participant’s home environment is dry, clean, ventilated, pest/contaminant-free, and properly maintained for safety.

So far, Sequoia Village has served 11 individuals and four of them have extended their membership past the introductory period. This partnership with DHSC led to a subsequent grant from Sequoia Healthcare District, which pays for subsidized memberships, home safety materials, medical alert subscriptions, and Lyft rides (in situations where volunteers were unavailable).

Next on the agenda, a new grant from DHSC will establish a partnership between Sequoia Village and a local home care agency (to deliver services post-hospitalization), Meals on Wheels (to increase access to fresh and healthy food), and a group that will coordinate follow up medical care (to ensure that patients receive appropriate post-discharge treatment). The overall goal is to provide DHSC patients with a seamless continuum of care.

Take-aways for other villages:

• Get to know the leaders of the hospitals and health care districts in your service area; explain the role your village plays in the aging services eco-system.
• Look for ways to partner with other organizations to holistically address the needs of older adults in your community.