News and Events

Tuesday, May 20, 2014

COA Care Transitions planning expansion to more hospitals

Care Transitions, Council on Aging’s program to reduce hospital readmissions, is expanding to four additional hospitals, bringing the total to nine regional hospitals in four counties which partner with COA to offer the health coaching program. Care Transitions is designed to prevent at-risk older adults from returning to the hospital within a few days or weeks of discharge.

The new hospitals are:

  • Mercy Health – Anderson Hospital
  • Mercy Health – Clermont Hospital
  • Mercy West Hospital
  • West Chester Hospital – UC Health


COA Care Transitions is currently available at:

  • The Christ Hospital
  • Clinton Memorial Hospital
  • The Jewish Hospital – Mercy Health
  • Mercy Health – Fairfield Hospital 
  • University of Cincinnati Medical Center – UC Health


In addition to receiving permission to expand, COA recently received a one-year extension of its contract for Care Transitions with the U.S. Centers for Medicare and Medicaid Services (CMS). Due to performance towards goals, COA received the maximum contract extension available at this time. A number of other sites received six-month extensions or were not renewed. CMS is evaluating Care Transitions initiatives around the country on their ability to prevent hospital readmissions, which saves money for Medicare.

This month, COA’s program was recognized by the Cincinnati USA Regional Chamber of Commerce as a finalist for a 2014 Business Award, in the category of Best New Product.

COA’s program is a collaborative effort with the hospitals, the Greater Cincinnati Health Council, and other local health organizations. It is based on a model developed by Eric Coleman, M.D., of the University of Colorado. The Coleman model is a 30-day intervention program. A trained health coach makes a home visit to Medicare patients who have been discharged from the hospital and follows up with phone calls over the 30-day period.
Health coaches focus on four “pillars” aimed at keeping patients in their homes and out of the hospital for 30 days or longer: 1) understanding and managing medications; 2) follow-up with primary care physician; 3) keeping a personal health record (coaches supply a booklet); and 4) recognizing and responding to “red flags” – warning signs that something is wrong.

For the third year of its CMS contract, Council on Aging is seeking to visit more than 6,000 discharged patients and prevent more than 1,400 potential hospital readmissions. Net savings to Medicare for 2012-14 are estimated at $1.28 million. 

More information about Care Transitions, including a patient video, is available on our web site.

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