Foundation for Senior Care Launches “Door-Through-Door” Program to Break Cycle of Repeated Hospitalizations

 “Coming home from the hospital or a stay at a skilled nursing facility should be about healing, not about struggling with lack of food, medicine, equipment or wondering if anyone is coming to help.” said Executive Director of the Foundation for Senior Care Rachel Mason. If one of those pieces is missing, the result is often a revolving door back into the hospital.  The recently launched “Door-Through-Door” program has been created to ensure that medical care plans and social support systems are in place before discharge so that clients can safely return home and focus on healing, breaking the cycle of repeated hospitalizations.

The Door-Through-Door program essentially incorporates the best of the Foundation’s advocacy program and transportation.  The Foundation’s Advocate Door-Through-Door Coordinator Darlene Weber will be the primary contact,  communicating with the hospital, the client and any agency or resource needed prior to discharge. She will be involved both before and after discharge, even driving clients home when there is no family member or friend available to do so.

“This program is such an obvious solution to the communications gap in the health care system,” Rachel said, “which is why I think we’ve had such great success from private grant funders to support the program expenses.” Most of the funding for the pilot program, estimated to cost around $64,000, has come from a health service contract from the Fallbrook Regional Health District and other private grant funders. “We are also extremely grateful to the Fallbrook Rotary club for funding the Door-Through-Door car which will allow us to get clients home from the hospital and for Darlene to conduct those pre and post hospitalization visits.”

“To keep this program viable for many years to come,” Rachel noted, “we will be asking for the community’s support with ongoing donations.” As with all programs available through the foundation, donations and bequests can be earmarked specifically to support the Door-Through-Door program. “As our community ages, it is important that we are here to help our neighbors be safe and independent in their own homes for as long as possible.”

Door-Through-Door Coordinator Darlene Weber stressed that she and Susan Baglien, the Foundation’s other long-time Advocate, have always been available to help seniors get necessary medical devices and resources. This new program expands the advocates role and creates a focused, dedicated approach to working with hospitals before, during and after a client is discharged and, if needed, to transport the client after discharge. Darlene is working now to get the word out about the program to the three nearest hospitals — Tri-City, Temecula Valley, and Palomar – and establishing relationships with their social workers.

As Darlene and Rachel noted, “We need to make sure hospitals and clients know that we exist and can help with this process.”The process varies with each individual. Seniors who have an adult child living nearby may not need this service if their son or daughter is able to coordinate with all the medical and social services required for their parent to heal. Many Fallbrook seniors, however, do not have family or friends who are able to perform this service.

“Those with insurance and their own funds to pay for resources have different needs of course from others who are under insured or lack adequate funds,” Darlene noted. “Insurance varies as to what specifically is covered and we can help find that out for them. For example, some policies pay for certain durable medical equipment while others may not. Clients who have the funds to pay for it themselves may only need our help to locate a convenient supplier. For clients who do not have adequate funds to cover the costs, we help them get the needed resources. Clients coming home after several months recovery at an extended care facility might have overgrown grass or need a ramp installed in their home, for example. If they have the funds to pay, we may only need to help find a fast and reliable landscape service and carpenter for them. For clients who lack the funds, we work with our other non-profit partner Helping Hands whose volunteers perform yard work or minor household repairs for seniors in need. Whatever the level of need, the mission of this program is fill it so that clients know they can return home safely and focus their attention on healing.”

Learn more about The Foundation for Senior Care at


The Foundation for Senior Care is a 501(c) (3) non-profit organization that serves the needs of seniors and disabled adults in Fallbrook. In addition to transportation services, the Foundation for Senior Care also offers Adult Day Care services at “The Club”, senior advocacy and a Computer Learning Center. The Foundation depends on business and individual donors to provide these essential services to the community. It is located at 135 S. Mission Rd. in Fallbrook, CA. Tax ID 95-3389263




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