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JASA Aging Services partnered with NYC hospitals and health plans to launch an age-friendly hospital-to-home transitional care model targeting social needs and reducing readmissions, combining patient-centered “what matters” care, home-based education, and in-language culturally appropriate support led by international medical 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FRIENDLY CROSS-SECTOR PROGRAM TO  \nADDRESS HEALTH-RELATED SOCIAL NEEDS AND  \nPREVENT AVOIDABLE HOSPITALIZATION  \nJose Martinez Escudero1, and Arielle Basch2, 1. JASA, New York, New York, United States, 2. JASA, Litchfield, Connecticut, United States  \nOlder adults face post-hospitalization risks including medication complexity, barriers to follow-up care, and limited understanding of how to manage health conditions at home. These challenges are exacerbated for patients with limited English proficiency, lower health literacy, and complex social needs. JASA Aging Services has partnered with hospitals and health plans in NYC to create an age-friendly hospital and home-based transitional care model to address social needs and reduce readmissions. It includes several innovative elements: age-friendly care across settings driven by “what matters” to the patient; home-based education to build trust and learn about the patient’s environment; an in-language, culturally appropriate model led by international medical graduates with extensive clinical knowledge and concordance of (10+) languages and cultures with patients. The program provides education, medication reconciliation, and vital sign monitoring while addressing social needs.  \nThe model shows early signs of success. Between February 1, 2024 and January 31, 2025, 1353 patients received JASA’s transitional care services of which 83% were connected to essential social services, 56% completed a healthcare proxy form, and 72% received essential support with their medications. We achieved a 38% reduction in readmissions and patients were 21% more likely to engage with a PCP compared to baseline data. Patient satisfaction scores exceed 97% .","cbCaihUWVVYJzrhE","https://ap.wps.com/l/cbCaihUWVVYJzrhE","pdf",46736,"English","# Abstract\n## Post-hospitalization risks\n## Program model and key innovations\n## Early outcomes and results","[{\"question\":\"What post-hospitalization risks does the program address?\",\"answer\":\"It targets medication complexity, barriers to follow-up care, and limited understanding of how to manage health conditions at home.\"},{\"question\":\"How is the age-friendly transitional care model designed?\",\"answer\":\"It provides patient-centered care across settings, home-based education, and in-language culturally appropriate delivery led by international medical graduates.\"},{\"question\":\"What early outcomes were reported between Feb 1, 2024 and Jan 31, 2025?\",\"answer\":\"Among 1,353 patients, 83% were connected to essential social services, 56% completed a healthcare proxy form, and 72% received essential medication support, alongside a 38% reduction in readmissions.\"}]","AN AGE FRIENDLY CROSS-SECTOR PROGRAM TO ADDRESS HEALTH-RELATED SOCIAL NEEDS AND PREVENT AVOIDABLE HOSPITALIZATION | PDF",1790636064]