Successful Care Transitions program receives contract extension

Thursday, February 12, 2015

COA’s health coaching program received a one-year contract extension from the U.S. Centers for Medicare and Medicaid Services (CMS). It is the second contract extension for the program. The vote of confidence follows a successful 2014 in which the program:

  • expanded to nine hospitals, 
  • completed more than 6,000 home visits by health coaches, and 
  • performed among the top 25 percent of Community Care Transitions Projects nationally.

Care Transitions provides health coaching for older adults who have been hospitalized for serious and usually chronic conditions, such as heart failure. It is designed to educate and empower patients to manage their recovery, adhere to their medical instructions, and avoid an all-too-common quick return to the hospital.

The 30-day intervention is based on model developed by Eric Coleman, M.D. of the University of Colorado. It begins with a home visit within three days of hospital discharge and includes three follow-up phone calls. Coaches help patients manage their medications, follow-up with doctors, and respond to warning signs that a condition is worsening.


In the first nine months of 2014, 3,126 patients completed the 30-day intervention. Compared with 2013, we achieved a 62 percent increase in the number of participants and a 10 percent increase in the rate of completion. Of those who started Care Transitions, 11.2 percent were readmitted to one of the participating hospitals within 30 days of discharge, This rate is significantly lower than the national readmission rate for Medicare patients, which is approximately 17 percent. It’s also 1 percent lower than in 2013.

Participating hospitals and partners

Council on Aging, 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 contract with the U.S. Centers for Medicare and Medicaid Services to develop a care transitions program for Medicare patients at hospitals in our region. The program is currently available at these hospitals: The Christ Hospital; Clinton Memorial Hospital; Mercy Health: The Jewish Hospital, Anderson Hospital, Clermont Hospital, and Fairfield Hospital, West Hospital; University of Cincinnati Medical Center; and UC Health - West Chester Hospital.

Bill’s story

Care Transitions patient Bill with health coach Jill
"I had so many bottles of medicine - new ones and old ones - it was a mess.  She helped me figure it all out and we made a list and all.  We got it down pat now." Bill, Care Transitions patient, with his Transitions Coach, Jill

Within a period of two months, Bill, age 85, went from a hospital to a nursing home, to a different hospital, followed by a different nursing home and then, finally, back to his own home. By the time he arrived home, he had accumulated more than 24 bottles of medicine. The pills had been given to him each day at the hospitals and nursing homes, so, when he was on his own, he knew little about when to take them or what each was for. Instructions he had been given were hard to read and understand. A heart bypass patient who needs to be precise about his medications, Bill was at high risk for a quick return to the hospital.

Bill’s story is not unusual. According to the Centers for Medicare and Medicaid Services, billions of dollars are spent annually on hospital re-admissions that could have been prevented. Common reasons include medication mix-ups, failure to follow-up with doctors, and being unaware or ignoring signs that a condition is worsening.

Fortunately, though, Bill was at Clinton Memorial Hospital, one of nine hospitals participating in Council on Aging’s Care Transitions program. There he met Jill, a COA health coach who checked in with him again when he was discharged to a nursing home and then finally met with him in his home.

“I think she’s an angel,” Bill said. “I was so sick when I was in the hospital and she came in there to help. And then she followed me around. Wherever I was at, there she was.”

Jill’s first priority was to get Bill’s medications in order, dispose of duplicates, and make one clear list that Bill could follow daily. They also talked about goals.

“When I was in the nursing home, my goal was to go home. And to be able to walk with a cane,” Bill said. “I’d be up walking the halls at three in the morning. You didn’t see anybody work harder than me. I wanted to go home.”