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JASA’s Care Transitions Intervention for Older Adults: Integrating Health Care and Social Services

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Being discharged from the hospital can be a high-risk episode, especially for older adults. To address the challenges faced when inpatient care ends and an older adult returns to the community, JASA has developed a home-based care transitions program to address the social determinants of health, reduce 30-day hospital readmissions and enable stable, home-based functioning.  JASA’s care transitions program provides non-clinical health and social services delivered primarily by international medical graduates. The program serves those covered by Medicaid and Medicare (dual eligibles) and the uninsured, and has been supported by managed care (Healthfirst) and hospital partners (including Maimonides Medical Center, Wyckoff Heights Medical Center and NYC H+H/Woodhull), which have faced financial penalties for 30-day readmissions. Please join our webinar to learn best practices for safe care transitions for older adults, and to hear about program implementation, collaboration with clinical partners and impact on patient’s health outcomes.  

This webinar includes complimentary ASWB CE credits.



Arielle Basch, MPH, MBA, is senior director of Health Services at JASA, and has created, built and led JASA’s Chronic Disease Management and Care Transitions programs. Her care transitions work was recognized by the John A. Hartford Foundation’s 2020 Business Innovation Award and has resulted in multiple hospital and managed care contracts. 

Karen Schmalbach is an International Medical Graduate and the Care Transitions project director at JASA, where she has helped to prevent hospital readmissions for clients by addressing social determinants of health and preventing adverse events, particularly those related to medications.


Participants in this webinar will be able to:

  • Identify at least four risks for readmission for older adults;
  • List best practices to support safe care transitions for older adults; and
  • Identify non-clinical health needs that should be addressed post-discharge.

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