Transforming Hospital-to-Home Transitions with Care and Innovation


Forging Partnerships for Better Health

In 2012, a groundbreaking collaboration was born, uniting Dignity Health hospitals Arizona, Foundation for Senior Living (FSL), and Mercy Care Plan under a common goal: to revolutionize the transition from hospital to home. Thus, the ACTIVATE (Advance Clients’ Transition to Independence via Actions that Empower) transitional care program emerged, a beacon of hope for patients navigating the delicate, tumultuous journey post-discharge. With a focus on individuals grappling with multiple co-morbidities and high re-hospitalization rates, ACTIVATE represents a paradigm shift in patient-centered care.

Empowering Patients, Saving Lives

At its core, ACTIVATE embodies the ethos of comprehensive care, drawing upon best practices from renowned models such as the Coleman Model and Project RED. Central to its success is the pivotal role of the Patient Care Advocate, FSL team members who seamlessly integrate with in-hospital medical staff to orchestrate post-discharge care with precision and compassion. From conducting home visits for psycho-social assessments and medication reconciliation to facilitating access to essential resources, the program leaves no stone unturned in ensuring patients’ well-being.

One such patient, Christie, attributes ACTIVATE for the quality of her livelihood today. Christie was 21 years old when she was diagnosed with diverticulitis. She was young, newly married and didn’t want to push her husband into early caregiving by undergoing major surgery. Years went by and her condition worsened to the point where she was forced to have the procedure. Five days later, her insurance canceled. Unable to afford new supplies, she had to wash and re-use her ostomy pouches, even going as far as to use grocery bags. Due to the lack of quality supplies, Christie ended up getting a severe infection that left her readmitted to the hospital. It was then she met FSL’s Patient Care Advocates who provided her a walker and ostomy bags for recovery, ensured she has access to nutritious food, and even helped get her back on insurance.

Addressing Social Determinants of Health

One of ACTIVATE’s most distinguishing features lies in its holistic approach to health, transcending medical boundaries to tackle social determinants head-on. By assessing factors such as medication affordability, transportation reliability, and housing stability, ACTIVATE aims to dismantle barriers that often precipitate re-hospitalization. Through pre-vetted and tailored referrals to community resources and ongoing support, patients are empowered to overcome obstacles and chart a course towards lasting health and stability. This model also helps patients avoid the additional time and stress that come with navigating the diverse and complex array of social services.

A Testament to Success: Reducing Readmissions, Restoring Lives

Since its inception, ACTIVATE has achieved remarkable milestones, slashing readmission rates in complex care populations from 28% to a mere 3% average. The team of Patient Care Advocates provides personalized resources navigation for thousands of patients each year. Beyond the metrics lie tangible improvements in health outcomes and significant reductions in healthcare costs, underscoring the program’s profound impact on individuals and communities alike.

Expanding Horizons: The Evolution of ACTIVATE Prime

Buoyed by its resounding success, ACTIVATE has expanded its reach beyond the confines of long-term care, encompassing Medicare, Veterans, and the uninsured in what is now known as the ACTIVATE Prime model. With a keen focus on measured 30–90-day readmission rates, the program continues to push boundaries and redefine standards of care with each passing day.

FSL Kindness Closet
FSL's Kndness Closet stands ready to equip patients with the supplies they need to recover

FSL: Pioneering Change, Enhancing Lives

At the helm of this transformative journey stands FSL, a beacon of hope for Arizona families grappling with a myriad of challenges. As a 501(c)(3) organization, FSL’s mission to make Arizona a safe place to age transcends mere provision of services; it embodies a commitment to promoting health, independence, and dignity for all. From battling hunger and illness to combating loneliness and substandard housing, FSL’s tireless efforts have left an indelible mark on countless lives, enriching the fabric of communities across the state.

For more information on FSL’s ACTIVATE program and its transformative impact, visit

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