Care Transitions

Care Transitions
A Care Transitions coach visits with a patient in the hospital

Care Transitions is a free health coaching and intervention program in Greater Cincinnati for older adults who have been hospitalized for serious and usually chronic conditions, such as heart failure. It is designed to:

  • Help frail seniors who have been discharged from the hospital avoid future preventable hospital admissions
  • Help patients access the most appropriate post-acute medical care and home and community-based services (and avoid the more costly nursing facility placements when not necessary)

Services and Benefits

When you`ve been sick, being discharged from the hospital can leave you feeling a bit overwhelmed. You may have new medications, for example. How are they affected by the medications you`re already taking? You may have detailed medical instructions to follow, need out-patient therapy, and have appointments to make with specialists. It`s a lot to keep straight!

Sometimes,with all these difficulties, people end up back in the hospital within a few weeks. That can take a toll on you and your family. But, often, a return visit to the hospital can be prevented. That`s where Care Transitions can help.

Care Transitions is designed to help you make a successful transition from the hospital to another care setting, such as your home. It`s free (covered by Medicare) and it can help you to feel more in control of your health care. 

If you are eligible for the program, you`ll receive a visit from a COA Care Transitions Coach before you leave the hospital. The coach will explain the program and walk you through a discharge checklist. The checklist helps ensure you understand your medical instructions and what to do as you transition home or to another care setting.

Your coach will conduct a home visit and three follow up phone calls to provide support during your transition from the hospital to your home. Your coach will visit and call at times that are convenient for you.

Over the next few weeks, the Care Transitions Coach will work with you and your caregiver to help you:

  • Better understand and manage your medications
  • Make a plan for follow up appointments with your primary care physician and other specialists
  • Recognize and respond to the warning signs or red flags that could mean your condition is worsening
  • Create a Personal Health Record that includes all the information you need to take with you to medical appointments
  • Connect to community resources that can help you maintain your health and independence

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Care Transitions Works

Ranked among the best of its kind, just 11 percent of Care Transitions patients are readmitted to the hospital within 30-days of their initial discharge, compared with the national average of 21.3 percent.* In 2015, more than 7,500 patients were accepted into our Care Transitions program and received an visit from a COA health coach.

*Program is a top performer in the Community Care Transitions Project of the U.S. Centers for Medicare and Medicaid Services. Readmission rate is based on July 2014 - June 2015 data and includes our nine participating hospitals only.


Eligibility Requirements

COA Care Transitions Specialists work with Medicare patients at participating hospitals who are at high risk for readmission after they are discharged home or to a nursing facility.

To be eligible to participate in Care Transitions, the patient must be:

  • admitted to a participating hospital: The Christ Hospital, Clinton Memorial Hospital, The Jewish Hospital, or the University of Cincinnati Medical Center
  • enrolled in traditional Medicare, and
  • at risk for hospital readmission after discharge due to any chronic illness or injury (heart disease, heart attack, pneumonia, diabetes, etc.).

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Additional Information

Council on Aging of Southwestern Ohio, in partnership with the Greater Cincinnati Health Council and several area hospitals and health care organizations, was one of the nation`s first recipients of a federal Medicare contract designed to reduce hospital admissions among seniors. Based on the proven Care Transitions Intervention developed by Dr. Eric Coleman of the University of Colorado, southwestern Ohio`s Care Transitions program uses coaching, health information technology, help with medications, and chronic disease self-management to help hospitalized seniors get home and stay home.

COA's contract with the Centers for Medicare and Medicaid Services ended on January 31, 2017, but Council on Aging is continuing to operate the program at The Christ Hospital, Clinton Memorial Hospital, The Jewish Hospital, and the University of Cincinnati Medical Center. 

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