Care Transitions program helping seniors stay out of the hospital

Thursday, October 31, 2013

Council on Aging’s Care Transitions program continues to grow and its success is attracting attention from health care leaders.

In September, a team from Kaiser Permanente, the nation’s largest non-profit health plan, visited COA to learn how we and our collaborating partners support the wellbeing of seniors and their ability to remain at home.  The success of the Care Transitions program was one factor in their decision to come here. 

The four-person team, called the Kaiser Permanente Innovation Consultancy, has met with a number of agencies and organizations across the country and selected southwest Ohio as a region that is on the leading edge in terms of support for older adults.  The Kaiser team is expected to visit again next spring to report on their findings. 

Kim Clark
Kim Clark, Care Transitions program manager

Earlier this month, Kim Clark, manager of the Care Transitions program, was invited to join the Community-based Care Transitions Program (CCTP) Learning Collaborative Faculty. The Learning Collaborative is a way for care transitions programs across the country to share their successes and lessons learned.  Faculty members are selected based on their leadership qualities, commitment to achieving results, and enthusiasm for sharing with and learning from others in the collaborative. 

Care Transitions is a health coaching and intervention program 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 more costly nursing facility placements)

COA’s Care Transitions program began as a small pilot at one hospital and was able to expand by winning a contract with the U.S. Centers for Medicare and Medicaid Services (CMS) for its Community-based Care Transitions Program.  To design and implement the expansion, COA formed the Southwest Ohio Care Transitions Collaborative with the Greater Cincinnati Health Council, several other health care organizations and five hospitals:  The Christ Hospital, Clinton Memorial Hospital, the Jewish Hospital-Mercy Health, Mercy Health-Fairfield Hospital, and University of Cincinnati Medical Center.

The most recent quarterly report from CMS shows that we served nearly 2,000 people between February 2012 and April 2013 and continue to reach more patients each quarter. While CMS does not allow us to release their readmission data, results show that the rate of 30-day hospital readmissions for participants in our program is below the average rate of other participants in the national Community-based Care Transitions Program. 

Care transitions is designed to achieve what is known as the “triple aim” of health care reform: Better Care, Better Health, and Lower Costs.