Care Transitions project wins national video award

Friday, December 14, 2012

A short video about a new program to reduce costly hospital is one of 20 semi-finalists in the Robert Wood Johnson Foundation`s Transitions to Better Care video contest.

The video was chosen from among more than 110 contest entrants and will be featured on the foundation`s Care About Your Care website beginning in February.  

In addition, the foundation will be hosting a Care About Your Care national discussion on care transitions and readmissions on Wednesday, February 13, 2013 in Washington, D.C. It will be streamed on a live webcast and the work of the southwestern Ohio project will be highlighted as part of the discussion.

The video was created by the Greater Cincinnati Health Council and features Care Transitions Manager Kim Clark and health coach Danielle Amrine, both of Council on Aging.

Speaking about the video contest, a spokesperson for the RWJ Foundation said: "The level of participation was inspiring, as well as the videos themselves and the enthusiasm behind them. The results being achieved in reducing readmissions and improving care transitions are very impressive. "

Care Transitions is a health coaching and intervention program in Greater Cincinnati for older adults who have been hospitalized. It is designed to:

  • Help seniors who have been discharged from the hospital avoid the need to return
  • Help patients access the most appropriate post-acute medical care and home and community-based services (avoiding the more costly nursing facility placements when not necessary).

The program is one of the first seven sites in the country to receive a contract with the Centers for Medicare and Medicaid Services as part of a national effort to reduce unnecessary hospital readmissions, improve health care and save money for Medicare.

The program is based on a national model that has been effective at empowering patients with chronic conditions to do more to manage their health care, It uses trained health coaches, employed by Council on Aging and stationed in five regional hospitals. After patients are discharged from the hospital, they receive a visit at home from a coach, along with follow-up phone calls over a 30-day period. 

The coach helps them understand and manage their medications; recognize and respond to symptom red flags; connect with primary care physicians; and access in-home and community services for long-term care.

The program is operated by the Southwest Ohio Care Transitions Collaborative at five regional hospitals. Partners include Council on Aging of Southwestern Ohio; the Greater

Cincinnati Health Council; Hamilton County Mental Health and Recovery Services Board; HealthBridge; Health Care Access Now; the Health Collaborative; and the following hospitals: The Christ Hospital; Clinton Memorial Hospital; The Jewish Hospital - Mercy Health; Mercy Health - Fairfield Hospital; and UC Health - University Hospital.