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Darioun and Mandi

Two months before he was to graduate from high school, Darioun was rushed to the Emergency Department at UCHealth Memorial Hospital in Colorado Springs, an arm of the University of Colorado Health System, with a gunshot wound to his abdomen. After numerous surgeries over many months, missing graduation day had faded to a lesser disappointment. Survival now dominated his attention as he faced a complex and extended recovery. His story turned out to be a model for the power of in-home care when it partners with a health system to improve patient outcomes and slash healthcare costs.

Several months after being shot, Darioun was released from the hospital, still with a feeding tube and unable to ingest anything, even water, by mouth. After 10 days, however, he was back in the hospital, this time with pneumonia. Before discharging him a second time with limited in-home support, Memorial turned to The Independence Center's "Hospital-to-Home" program.

The IC is a local, not-for-profit organization that specializes in services for persons with disabilities. It had created "Hospital-to-Home," or H2H, in cooperation with Memorial.

Acute, Post-Acute Partnership

Are SNFs Expensive Prisons?

Mandi Strantz, Care Transition Coordinator for The IC, knows well the pitfalls of transitioning people with disabilities to a SNF instead of to their homes. "There's a disturbing trend when people with complex cases are hospitalized and are not recovering quickly enough. They are often transferred to nursing homes, where many patients find themselves trapped.

"After not being in their homes for an extended period of time, bills go unpaid, life moves on, and they are in danger of losing the ability to ever move back home. Even if they are still able to live a life of independence, many individuals do not have the necessary network of resources in place to escape the clutches of institutional living.

"That is how individuals get stuck there, and have a very difficult time getting back home, and end up losing everything they have. So we want to have a paradigm shift in thinking, to say 'let's get people home' — where it is better for them as a person, it is better for their health, and it is cheaper."

The IC provides a wide range of services for persons with disabilities in nine Colorado counties. The IC also operates a home health agency that specializes in the Medicaid waiver program known as In-Home Support Services, through which it employs in-home caregivers who care for their own family members under that state program.

In 2015, CEO Patricia Yeager, PhD was alerted, by a board member familiar with the national home healthcare sector, to the crisis of people with disabilities trapped in hospitals long after they could have been discharged, or transferred to a Skilled Nursing Facility with little hope of ever leaving. (See Sidebar)

Leading a mission-driven, not-for-profit organization, CEO Yeager realized this crisis was custom made for The IC's skill set — even at Medicaid reimbursement rates. Out of those early conversations, a transitional care program emerged and was named "Hospital-to-Home" to signal its intent to bypass a SNF admission on the way from hospital discharge to home care.

After conversations with state Medicaid officials, outside consultants, and Joseph Foecking, Memorial's Director of Rehabilitation, The IC staff began program design. One of its first moves was to bring its plan to the attention of the Colorado Health Foundation, which awarded The IC a startup grant.

In its first 15 months, H2H made it possible for 26 people to come home instead of spending months in a hospital or skilled nursing facility bed. Foecking estimates that every hospital day avoided saves the state — or the hospital itself in charity cases — at least $2,000.

"Multiply that by 26 patients times the number of days avoided, which varies of course, and savings like these quickly attract the attention of hospital CFOs," Foecking told us.

H2H Helps Darioun Graduate

As his 19th birthday approached, Darioun had a full-time caregiver, his Aunt Sonya, who became an employee of The IC's Home Health department through the H2H program. Further, the IC's benefits department helped Darioun get the benefits he needed to pay for his care and arranged transportation to and from high school until he graduated. Darioun was the first in his family to graduate from high school. He has had a full recovery and now lives on his own.

When asked about his experience with The IC's H2H program, Darioun says he is extremely grateful, adding, "I got a chance to meet so many people at The IC. They have helped me understand that everybody with disabilities are not helpless."

The IC wraps additional services around its home health patients who have disabilities that qualify them for the Center's Independent Living side. Darioun also benefited from the organization's peer support service, through which The IC partnered him with an individual who had similar experiences. They were able to talk about the challenges, the occasional depression and discouragement, and how hard it was not to be able to enjoy the taste of food.

From Pilot to Program

So far, Dr. Yeager told us, H2H has been an overwhelming success, both by beating initial goals for the number of patients transitioned to home care and for the small number of patients readmitted to the hospital. "The results of the pilot program are clear," she said. "By providing needed supports for patients recovering in their homes, everyone wins."

One might argue, "except for the SNFs."

"The future of the H2H program looks bright," she added, referring to the pilot program that is now transitioning to a sustainable program Memorial is exploring. Going forward, she is hopeful other local hospitals will recognize the value of H2H's impact on patients and cost-effective outcomes and partner with The IC.

CEO Patricia Yeager is open to inquiries from home health and home care agencies as well as from other Independent Living centers serving people with disabilities. Contact on the web at or by calling 719-471-8181.


©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.