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Regional Care Transitions Program Works to Keep Residents Home

Thursday, August 2, 2012
by Gwynn Stewart

From his front porch in Marietta, 85-year-old Robert Hill has an extraordinary view of the beautiful Muskingum River.  Near the historic Harmar Village, the Hills make their home. Robert recently returned there from a stay in the hospital for a new pacemaker.

Carolyn Ditchendorf, LSW, a Transitions Coach with the Area Agency on Aging 8 (AAA8) and its Medicare Community-Based Care Transitions Program (CCTP) visited Robert to help make the transition from the hospital as seamless as possible.

Following discharge from a hospital, patients often require care from different medical professionals in many settings. A Transition Coach works with the patient and family for four weeks after a hospital stay to help them be better prepared to take care of their health conditions and help them meet their needs. This program focuses on the patient, and family or caregiver educating them about how to better self-manage their healthcare.

“I found it very helpful to review the discharge plan and all of the medications,” said Robert. “It was very reassuring to me to have support from the program. I also had a list of questions for the doctor when we returned for my check-up.” Transitions Coach Carolyn explains that Robert also gets great support at home from Judy, his wife of almost 62 years. “He is doing a great job of recording his blood pressure and blood sugar information to take to his physicians as well,” added Carolyn.

“Following his recovery, Robert set a personal goal to return to the classroom,” explained Carolyn. He is a retired Professor Emeritus of Political Science at Marietta College, and will return to the Learning in Retirement program this fall when he will teach an 8-week course on the American Constitution.

“There is an obvious underlying goal of Care Transitions to reduce unnecessary hospital readmissions and reduce Medicare costs,” said AAA8 Director Rick Hindman.  “But more importantly, the goal is to empower people to be an active part of their health care. It provides proven supports for individuals to help them heal and be at home – where most people say they would rather be.”

This 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.

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