After five months of inpatient care, Tom was finally able to go home.
Through the Hospital Discharge Program, he transitioned into subsidized housing with daily in-home support and care coordination, making a safe return from hospital to home possible.
Homebridge and the Institute on Aging have partnered to launch this pilot program, providing comprehensive wraparound services for patients who are medically ready for discharge but lack the support needed to leave safely.
For Tom, this program has been transformative.
“I want to take a walk on the beach,” he says. “And do a cold plunge.”
Tom sits and smiles for the camera. Photo by Ana Gonzalez.
Four months ago, those goals felt out of reach. When Tom first returned home, he was in a wheelchair. Today, he walks for 30 minutes and recently made the half-mile trip to his local Trader Joe’s on foot. With simple home modifications, he’s regained the ability to get in and out of the shower on his own - milestones that signal more than physical progress, but autonomy, dignity, and confidence.
His caregiver, Nate, has witnessed that change up close. With consistent support, structure, and trust, Tom has moved beyond stabilization to active recovery - building routines, setting goals, and pushing himself further each week.
Tom’s resilience, however, didn’t begin here.
Born in the Midwest, Tom lost both of his parents at age six and was separated from his siblings by the court. At 15, determined to find them, he boarded a plane to California alone - “probably the bravest thing I ever did,” he recalls.
Over the years, he built a life marked by perseverance, curiosity, and connection. He pursued a four-year degree in San Mateo, made the Dean’s List twice, overcame alcohol addiction, and eventually worked as a luxury cab driver - forming relationships with people from all walks of life.
An avid car collector, he still lights up talking about the vehicles he once owned - a ’65 Bonneville and an old 1950 truck with suicide doors - each tied to a story, a place, a moment in time.
“Lots of great memories,” he says. “Not too many regrets.”
Even during periods of homelessness, Tom found a community. He proudly recalls being part of a group he calls the “K-Mart Gang,” a close-knit circle who looked out for one another. He shares that their local K-Mart was next door to a 24-hour Denny’s, where they would spend nights over a Grand Slam and finding ways to get by.
“Some of my best years were when I was homeless,” he says - reflecting not on hardship, but on the relationships and resilience those years demanded.
“Make your own luck,” he adds, I’ve had so much luck in my life, it’s unbelievable.”
Today, Tom’s progress reflects what becomes possible when people are not only discharged but truly supported in returning home. With daily care and stability, he is rebuilding strength and independence while creating a routine - one step at a time.
His progress is a powerful example of what’s possible when people not only get care, but the right care, at the right time, in the right place.
And for a growing number of older adults, like Tom, that place is home.
