Improving the Social Determinants of Health

Southern Maine Agency on Aging understands that one's health is multi-faceted and that good health is not only determined by our physiological makeup and healthcare habits, but also determined significantly by access to social and economic opportunities.

The Southern Maine Agency on Aging provides support and services linked to improving the social determinants of health with the goal of reducing 30-day readmission rates post acute care and improving emergency department usage and hospital admission rates.


Reducing 30-Day Readmission Rates Post Acute Care

sample packaging for meals including welcome pamphlet, orange delivery bag, and meal description tag
• Meals are nutritionally balanced and provide 33% of daily caloric requirements

• Catered especially for SMAA by leading Maine caterer

• Maine-sourced produce, flash frozen for freshness

• Sustainably-packaged

• Meals are delivered frozen and are easily heated in the microwave or in the oven on demand

Simply Delivered Meals

A demonstrated return on investment of 387% and a 2 point (16%) reduction in readmission rates were observed as a result of providing 7 meals post-discharge to patients enrolled in the Coleman Model of Care Transitions who were at high risk for readmission. This was observed in a two-year pilot study conducted by SMAA with Maine Medical Center involving 622 patients.

SMAA Offers Home Delivered Meals with a Visual Check-in Post Discharge

Ideal for hospital or skilled nursing facility patients discharged from post acute care who are at a high risk of readmission or with mobility issues (COPD, HF, joint replacement).

  • 10-14 meals delivered within 48 hours of discharge. Meal options include heart healthy, diabetic friendly, renal friendly, pureed, gluten free, and vegetarian.

  • Meals accompanied with a visual safety check-in to determine if additional follow-up care is needed.

  • Visual check-in report shared with insurer and/or physician practice for follow up.

Post Acute Care Community Transition Intervention

This service utilizes highly-trained community resource specialists to follow and support a patient's transition home for 30-days or more post discharge from a hospital or skilled nursing facility. The community transition service is adaptable with other medically oriented care transition models. The focus is on the social determinants of health and allows a provider or insurer to fully understand the patient's social and economic environment. The goal is to assist the patient in becoming a more active participant in their healthcare needs using an agreed upon Community Resource Connection Plan.

What to Expect

  • Provider or insurer identifies appropriate patients

  • Patients receive meals within 48 hours post discharge

  • SMAA Community Resource Specialist facilitates a comprehensive at-home risk assessment

  • SMAA and the patient create a Community Resource Connection Plan based on the at-home risk assessment. This information is shared with the provider/insurer case managers.

  • Activation of the plan may be through SMAA or the provider/insurers case managers.

  • SMAA activation of the plan includes close working relationship with the provider or insurer's discharge team/case managers.


Improving Emergency Department Usage and Hospital Admission Rates

Community Solutions Intervention

This service connects patients with our Community Resource Specialist who are struggling to manage chronic conditions. The focus is on the social determinants of health with emphasis on helping patients secure needed services with support in identifying, locating and applying for such benefits. The provision of needed benefits helps patients self-manage chronic conditions with the goal of reducing their ED usage and hospital admission rate. Patients are followed by a Community Resource Specialist for 90 days or more depending on need.

What to Expect

  • Provider or insurer identifies appropriate patients

  • SMAA Community Resource Specialist facilitates a comprehensive at-home risk assessment within 3-5 days of referral

  • SMAA and the patient create a Community Resource Connection Plan based on the at-home risk assessment. This information is shared with the provider/insurer case managers.

  • Activation includes 1:1 help for the patient in understanding and accessing needed services, in-home face to face counseling sessions, and follow-up tied to identifying and removing social and economic barriers detrimental to health and well-being.

  • SMAA activation of the plan includes close working relationships with the provider or insurer discharge team/case managers.

  • SMAA follows patient for 90-days or more post referral with reports to insurer or provider.