Public Hearing: Helping Hospital and Nursing Home Patients Return to the Community

AgeWays Nonprofit Senior Services is looking for public input on a program that would assist nursing home and hospital patients transition back into the community. A public hearing by Zoom is set for 1 p.m. Friday, Feb. 16. The Annual Implementation Plan requires input from the public, as it will amend AgeWays’ budget for fiscal year 2024.

Person-Centered Planning

The goal of the Care Transitions Service is to prevent re-institutionalization. Discharge planning will include coaching and post-discharge supports by a health worker who will conduct an assessment and develop a person-centered service plan. This plan will include connections to local services and supports, ensure primary care follow-up, medical transportation coordination, red flag warning education, medication review, and weekly follow up for 30 days post-discharge from a hospital, nursing home, or other healthcare institution.

The Care Transitions Service will aim to fill a gap in our community for older adults who are not eligible for care transitions support through other programs, such as Medicaid-funded Care Transitions. Poor management of transitions in care have been linked to poor health outcomes and increased costs for older adults.

Comment Online or Offline

You need not be on the Zoom call to give your comments. They can be sent to or to Taylor Clark, Ageways, 29100 Northwestern Highway, Ste. 400, Southfield, MI 48034.

To join the Zoom hearing, go to

For more information, contact Taylor Clark at 248-310-3115 or at