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Regional Care Transitions Program Sees Successes

Monday, June 9, 2014
by Gwynn Stewart

A unique multi-county, multi-hospital collaborative effort among five hospitals and three Area Agencies on Aging (AAAs) awarded funding for the Medicare Community-Based Care Transitions Program (CCTP) through the Centers for Medicare & Medicaid Services (CMS) is seeing results. The program is designed to make the transition from the hospital to another setting as seamless as possible.


Targeting a 26-county region including rural Appalachia, this program will work to further reduce unnecessary re-admissions and achieve a reduction in Medicare costs. The target for this program is Medicare Fee-for-Service patients who are leaving the hospital for home or a nursing home.

“While there is an obvious underlying goal to reduce unnecessary hospital re-admissions and reduce Medicare costs, more importantly, our goal is to empower people to be an active part of their health care,” said AAA8 Director Rick Hindman. “The program provides proven supports for individuals to help them heal and be at home – where most people say they would rather be. The Area Agencies on Aging are focused on connecting individuals to key home and community-based care resources,” added Hindman.

The program focuses directly on improved patient outcomes such as reduced readmission to hospitals, decreased emergency department visits, discharging patients to the most appropriate, cost effective setting and streamlining access to quality long-term services and support. Care Transitions supports patients in learning more about their illness and healthcare needs.

“We encourage patients to ask questions to better understand and manage their illnesses, to know their medications, and to communicate and follow up with their doctors,” said AAA8 Program Development Coordinator, Mindy Cayton. “Recent surveys of program participants showed that from the time they enrolled until the end of the program, there was a significant increase in their understanding of their personal role and the responsibility of their own health care.”

When surveyed, 98 percent of Care Transitions program participants agreed that “when all is said and done, they are responsible for taking care of their health and that taking an active role is important” versus 85 percent just 30 days earlier. The active role includes a better understanding of what medications they take and why, how and when to follow-up with a doctor, or making necessary lifestyle changes.

The participating Area Agencies on Aging include Buckeye Hills AAA8 – Southeast Ohio (Marietta) as the lead agency, AAA6 - Central Ohio (Columbus) and AAA7 – Southern Ohio (Rio Grande). The hospital partners include Fairfield Medical Center (Lancaster), Memorial Health Systems (Marietta), Adena Regional Medical Center (Chillicothe), Holzer Medical Center (Gallipolis) and the Southern Ohio Medical Center (Portsmouth). Learn more at http://www.areaagency8.org/services/care-transitions.

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A Program of Buckeye Hills-Hocking Valley Regional Development District