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This year’s theme for Older Americans Month is “Get into the Act.” Simply put, this means that seniors are active in taking charge of their own health, and getting involved in their surrounding community. In a partnership with Robert Wood Johnson Hospital, Jewish Family & Children’s Service of Greater Mercer County has developed Secure@Home Hamilton, a transitional care program that supports older adults in taking charge of their own health post-hospitalization.

Jewish Family & Children’s Service of Greater Mercer County is a social service agency that serves many individuals and families in the area. The agency provides case management services, counseling, a kosher food pantry and a large senior services department. Most programs are staffed by dedicated social workers. Through a grant funded by Bristol-Myers Squibb, Secure@Home Hamilton’s goal is to prevent hospital readmissions of seniors in Mercer County. Countless senior citizens are discharged from hospitals, and are unfortunately readmitted within 30 days of discharge.

Within the first year of implementation, Secure@Home Hamilton has connected with over 60 clients in the Mercer County area. The program advocates an innovative, interdisciplinary team approach through its use of two nurses and a social worker who collaborate on a client’s care plan. The client’s medical and social concerns can be better addressed through this holistic and comprehensive system of care. Many clients in the program need assistance securing transportation services, finding reliable home health care and medication management.

One client in particular, Evelyn, greatly benefitted from the Secure@Home Hamilton program. Evelyn is a woman in her eighties who lives alone in a low-income senior building. Once leaving the hospital she needed assistance with transportation and meal delivery. Katrina Brophy, LSW, the Secure@Home Hamilton social worker, visited Evelyn in her apartment to conduct an assessment and collaborate with her regarding services she needed in the post-hospital transition. The social worker enrolled Evelyn in a free county transportation program, TRADE, and arranged meals with the Red Cross Meals on Wheels. These two services aided the client in this difficult time. Evelyn reported to the social worker and nurse how grateful she was for the rides to her doctors that the program provides. The client now has reliable, free transportation and prepared meals delivered to her. She has not been readmitted to the hospital. There are a number of clients in this program who were in need of just a small change. These small changes have contributed to the low readmissions rate of less than 10%. Now that the program is in its second year Secure@Home Hamilton looks to replicate these positive results. In celebration of Older Americans Month, Secure@Home Hamilton serves as a model for seniors to take charge of their health and live as independently as possible.