30 Jul 2025 |


In collaboration with ESWA, this program has had a profound, lasting impact on the health and well-being of the older adults we collectively serve. By providing timely follow-ups, medication reconciliation, and personalized coaching, the program has helped our members avoid unnecessary hospital visits and better manage their care at home. It also reduces social isolation by connecting participants—many of whom lack strong support networks—with regular companion visits, meals, social activities, and digital tools to stay connected with family and providers.
Since its inception, the program has reached over 7,500 senior residents in Massachusetts, leading to reduced health care costs and a 96% satisfaction rate among surveyed participants. The Care Transitions Program only continues to expand its reach, with a projection of reaching over 3000 members in 2025, and growth via subcontracting to over 19 Massachusetts-based Aging Service Access Points. This initiative exemplifies the power of community-based innovation in linking health and social care, and we are grateful for the opportunity to collaborate on work that makes such a meaningful difference in our members’ lives.