Hospital 2 Home

A Smoother, Safer Return Home

Hospital 2 Home (H2H) helps older adults and individuals with chronic illness, memory loss, or disabilities transition safely from hospital or rehab back to their homes. We work directly with caregivers and community partners to ensure continuity of care, reduced stress, and improved health outcomes.

The goal is simple: our transitional care services make the journey home less overwhelming for both clients and caregivers by providing…

We collaborate with healthcare providers and community partners to ensure seamless continuity of care
Our team is fast to identify and respond when unexpected challenges arise
We offer short-term relief and hands-on guidance for caregivers managing new responsibilities
During an overwhelming time, we help connect you to long-term support, education, and programs that enhance safety and quality of life

A caregiver and an elderly woman sharing an emotional moment in a senior care facility, with the caregiver comforting the woman who appears to be in distress.

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What is Unique About
Hospital 2 Home

Our licensed, compassionate professionals have extensive experience supporting older adults and those with disabilities - including those with chronic conditions and/or cognitive impairment.

We will advocate for you and stand beside you during a stressful and vulnerable time
We’re committed to swiftly responding to referrals
Our holistic approach allows us to personalize the medical, emotional, and social wellbeing care plan
As a part of Nevada Senior Services, we seamlessly integrate to a full continuum of care services - including adult day programs, caregiver support, home safety assessments, and more
The Nevada Aging and Disability Services Division funds H2H, ensuring equitable access to essential services

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Submit a Referral

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Why Transitions Matter

Returning home after a hospital stay can feel overwhelming — especially for older adults or those managing multiple health conditions. Transitional moments often come with risks such as:

medication errors
confusion around discharge plans
difficulty following instructions
limited support at home
caregiver stress and burnout

For individuals with memory loss or dementia, these risks are even higher. Research shows that people living with dementia are twice as likely to be rehospitalized and face increased risks for delirium, falls, and complications.

Hospital 2 Home exists to bridge this gap — for all clients, and with specialized dementia-capable expertise when needed.

One in 2,800

Research shows that structured transitional care can reduce 30-day hospital readmissions by 25–40%.
Nevada 30-Day Medicare Readmission Rate: 34%
Hospital 2 Home Readmission Rate: 1 readmission in 2,800 cases (equivalent to: ~.034%)

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Benefits

Research shows older adults who receive structured transitional care support are around 25-40% less likely to be readmitted to hospital within 30 days, thanks to improved coordination and follow-up.

Hospital 2 Home helps clients and caregivers achieve:

Better health outcomes and greater medical stability
Reduced caregiver burden
Improved patient engagement
Easier access to long-term care resources
Stronger coordination across care settings
Prolonged safety and independence at home

Learn More

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Who We Serve

We support adults in Southern Nevada who are:

transitioning home after a hospital or rehab stay
living with chronic illness, disability, dementia, or functional limitations
in need of caregiver guidance or community resource support
living alone and vulnerable during transitions
facing challenges that increase the risk of readmission

We are not limited to dementia-specific cases — we serve individuals with all diagnoses and levels of complexity.

Get in Touch

Meet the Team

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Betty Russell, LCSW
Director of Hospital 2 Home

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Ryan
Respite Coach

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Abbey, BS, CMC
Administrative Coordinator & Aging Life Care Specialist

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Yoans
Care Transition Specialist

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Manny
Respite Coach

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Jackie
Care Transition Specialist

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Marie
Case Manager/Lead Respite Coach

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Eileen
Program Coordinator

Join Our Team

If you are passionate about helping those most vulnerable in our community while leading with kindness, you’re in the right place! We’re immediately hiring full-time, remote positions including:

Licensed social workers
Care transition specialists
Respite caregivers

Please visit our career page for more information and application details.

Explore Careers

How H2H Works

Referrals come from hospitals, rehab centers, medical providers, and community partners. Caregivers may also call with questions.
Our team connects with the client and caregiver within 1–2 days of discharge.
A Care Transition Specialist helps coordinate care, identify risks, monitor symptoms, and ensure follow-up appointments are completed.
Trained respite coaches and dementia-capable staff support individuals with memory loss or cognitive challenges.
After the initial 30 days, we help connect clients to long-term services such as in-home care, home safety programs, meals, transportation, caregiver education, adult day services, and more.