Hospital to Home

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What is Care Transitions?

JASA’s Care Transitions program is a hospital and home-based intervention that aims to prevent avoidable hospital admissions, enable stable home-based functioning, and support more good days in the community for older adults. The program is person-centered, emphasizing “what matters” most to the patient, and provides support in a few ways:

  • Intensive patient education is provided to explain discharge instructions, symptom management, and what to do when a condition worsens. Information is delivered in the patient’s primary language in a way that is digestible and actionable for patients with lower health literacy levels, limited English proficiency, or for those who may be visually or hearing impaired.

  • Medication support is offered to ensure patients have their medications and know how and when to take them, and what they are for.  

  • Physician follow-up is provided to ensure coordination and seamless communications with community physicians.  

  • Social support and connection to food and nutrition, transportation, housing, and other critical community services.

  • Mental Health Service referrals are provided to patients who could benefit from support in the community.   

  • In-home assessment to identify environmental and other safety risks in the home and address functional needs and fall risks.

JASA’s Care Transitions program is led by International Medical Graduates (IMGs), who have gone to medical school overseas and share the cultures and languages of many patients. JASA currently delivers the program in English, Spanish, Chinese, Russian, Haitian Creole, French, Hindi, Urdu, Punjabi, and Igbo and emphasizes cultural understanding, in-language communication, and building trusted relationships.  

The program is flexible and can support patients who are transitioning across settings from hospital to home, or who may not have been hospitalized, but have social or other risks in the community. The program can assist patients for 90 days or longer depending on need.

If you or someone you know needs help transitioning between care settings, email

Program Results

  • JASA’s Care Transitions program has helped select partners achieve a 12% readmission rate which is equivalent to a 40% reduction in readmissions.

  • Patients participating in the JASA intervention were significantly more likely to engage with a PCP and have a strong alignment with their primary care provider (>20% increase).

  • Patient satisfaction surveys demonstrate an extremely positive impact on patients and their caregivers.

Community Resources We Refer to

  • Food and Nutrition Services: Congregate Meals, Home Delivered Meals, SNAP, Medically Tailored Meals

  • Link to Primary Care Providers/House Calls/Urgent Care/Specialists

  • Home Care

  • Mental Health Services

  • Medicaid Enrollment Services

  • Transportation Services

  • Adult Protective Services 

  • Caregiver Support (Respite Program, support groups)

  • Housing Services

  • Emergency Cash Assistance

  • Home Energy Assistance Program 

  • Rent Freeze Programs 

  • LEAP/Legal Assistance

  • Smoking Cessation

  • Falls Prevention

  • Help obtaining Assistive Devices and other Durable Medical Equipment

  • Flu, COVID and Other Vaccines

  • Skilled Services

  • Friendly Visitor, JASAChat, and Older Adult Centers for Social Connection

Eligibility Criteria

  • Must be 18-years or older

  • Lives in NYC, Long Island or Westchester

  • Speaks English, Spanish, Chinese, Russian, Haitian Creole, Hindi, Punjabi, Urdu or Igbo

  • Complex health and social needs, including: polypharmacy, multiple comorbidities, food, transportation, housing or other social needs

JASA’s Care Transitions program is proud to partner with the following healthcare organizations, supporting their patients and members as they transition back to the community: 

  • Maimonides Medical Center

  • Wyckoff Heights Medical Center

  • Healthfirst

  • EmblemHealth

  • MJHS/Elderplan

Meet Our Team

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