Piloted and administered by AAAII

By William K. Alcorn



Area Agency on Aging 11 is providing care transition services to seniors under a new federal program proven to reduce readmissions to the hospital and save the Medicare program money.

The Centers for Medicare & Medicaid Services approved AAA11 as the provider of five years of care transition services for up to 10,000 eligible Medicare beneficiaries using the Community-based Care Transition Program (CCTP).

The CCTP, created by the The Patient Protection and Affordable Care Act (PPACA), commonly called Obamacare or the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing avoidable readmissions for high-risk Medicare beneficiaries.

The local AAA11 won the contract on the basis of a pilot project it conducted in 2011 that reduced avoidable readmission rates for PASSPORT consumers who had targeted diagnoses of renal failure, pneumonia, congestive heart failure from about 20 percent to about 13 percent, said Joseph Rossi, AAA11 chief executive officer.

Ohio’s PASSPORT Medicaid waiver program helps Medicaid-eligible older citizens get the long-term services and support they need to stay in their homes.

In the three counties targeted for this project — Columbiana, Mahoning and Trumbull — the cost to Medicare for average readmission within 30 days of discharge from a health care facility is about $9,600 per patient or some $1.7 million. The Centers for Medicare & Medicaid Services (CMS) is projecting significant savings through this program by reducing those avoidable readmission costs, Rossi said.

This program is one of the largest initiatives for AAA11 since the PASSPORT home and community based program began. Care Transitions not only helps older adults to take control of their health, it has the potential of significant savings for Medicare, he said.

Area Agency care transition coaches are located in seven hospitals in the tri-county area.

Under the program, which is free for patients about to be discharged from the hospital, coaches teach patients self-management skills to ensure their health needs are met once they transition from the hospital to home or other care setting.

Goals include improving quality of care, reducing readmissions for high risk beneficiaries, and documenting measurable savings to the Medicare program, Rossi said.

Studies have shown that the top reason for avoidable readmission is medication discrepancies; meaning patients fail to fill prescriptions, fail to take their medications regularly or cut their doses in half. The second most common reason for avoidable readmissions is lack of or no follow-up with a doctor, said Lisa Solley, AAA11 chief of Community Relations, Wellness, Training and Human Resources.

The project utilizes multiple interventions, including the proven, evidenced-based model Coleman Care Transitions Intervention coaching, medication reconciliation, improved communication and post-acute provider forums, to reduce avoidable hospital readmissions by 20 percent over the next two years, Rossi said.

Area Agency on Aging 11 has hired and is continuing to hire additional staff, and invested nearly $50,000 in training 42 staff members in the Coleman Care Transitions Intervention coaching model prior to receiving the CMS award, he said.

The coaches, licensed social workers and registered nurses, visit eligible patients in the hospital prior to discharge and again a few days later at home, and call the patient at least three times during the 30-day period after discharge, said Kim Varley, AAA11 manager for home and community based services.

Coaches also help patients learn about their medications and how to take them; make them aware of signs that indicate their health is getting worse, the third top reason for avoidable hospital readmissions; and prepares the patient for follow-up visits with their doctor. If necessary, they help get a family doctor and link them to the services they need, said Varley, a registered nurse.

Because medication discrepancies is the biggest problem, if a patient has six or more medications, he of she is called to ensure they have medication and see if they have questions.

“Our whole purpose is to teach patients how to manage health care needs, not to try and talk them out of going to hospital if there is an emergency. Also, as part of the coaching, and separate from the hospital, we have the ability to refer to other agencies.

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