Connect-Home Collaborative


Transitioning home using a person-centered approach.

Our Connect-Home Collaborative is dedicated to expanding interventions for older adults to successfully transition home after a post-acute care stay and address gaps in care that can lead to isolation, increased emergency room visits, hospitalization and reduced quality of life.


Since its launch in 2018, the work under this Collaborative has successfully reached 875 older adults in seven post-acute care sites located in Maryland, Michigan, New Jersey, New York, North Carolina, Pennsylvania and Wisconsin. Each of the seven sites demonstrated improvement in care transition and quality of life measures and continue to achieve major program goals, including one site’s attainment of the lowest hospital readmission rates in their county.

Expanding our work to reach older adults in affordable housing in Brooklyn, New York.

We launched a third phase of work under this Collaborative in 2022 to specifically support older adults in affordable housing settings in Brooklyn, New York adversely affected by the COVID-19 pandemic. The initiative is strengthening the capacity of existing staff in affordable housing to identify older adults most at risk of hospitalization, developing strategies to meet their needs and empowering older adults to successfully age independently at home.

Better transitional care ensures continued care at home.

According to the Centers for Medicaid and Medicare Services, 76 percent of 30-day hospital readmissions are preventable. To remain healthy and independent at home, older adults benefit from better transitional care, which is defined as a set of actions that ensure the coordination and continuity of healthcare as they transfer from one location to another.


Connect-Home empowers healthcare teams to provide excellent transitional care, improving patient and caregiver experiences and preparedness for discharge. Additional work in progress indicates Connect-Home is a sustainable intervention that contributes to continued care at home without hospital readmission.

Dr. Mark Toles

Created by Mark Toles, PhD, RN, FAAN at The University of North Carolina at Chapel Hill (UNC), Connect-Home is a proven intervention that empowers older adults and their caregivers to manage illnesses at home and prevent avoidable re-hospitalizations. Dr. Toles is an associate professor at UNC with expertise in nursing care of older adults and transitional care of older adults as they transfer between settings and providers of healthcare.


Funded by the National Institutes of Health, Dr. Toles is conducting a randomized and controlled trial of his successfully piloted Connect-Home intervention in a variety of settings.

Learn more about Dr. Toles:

Connect-Home: Testing the Efficacy of Transitional Care of Patients and Caregivers during Transitions from Skilled Nursing to Home


“Partnering with Lutheran Services in America expedites implementation of a transitional care intervention that improves the health and quality of life of older adults and addresses the needs of caregivers at home.”

Dr. Mark Toles, PhD, RN, FAAN

The University of North Carolina at Chapel Hill




The Connect-Home Collaborative: Scaling Up Transitional Care for Post-acute Care Patients and their Families — This report provides background information on the Connect-Home model, the program’s goals for improving the quality of care, the idea of care transitions as a bridge from one healthcare setting to the next and our implementation of the model through our Connect-Home Collaborative.


Susan Newton
Senior Director of Strategic Initiatives