Seated is Pamela K. Matura, Executive Director with the Area Agency on Aging District 7, and T. Wayne Munro, MD, Chief Executive Officer of Holzer Health System. Standing, from left, are Connie Montgomery, RN, AAA7 Care Transitions Coach; Bonnie Dingess, MSW, LISW-S, AAA7 Director of Long-Term Care Programs at the Area Agency on Aging District 7 (AAA7); Rhonda Dailey, MSN, RN, Vice President of Patient Care Services with Holzer Health System Jackson Hospital; and John Cunningham, Executive Vice President and Chief Administrative Officer for Holzer Health System.

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RIO GRANDE — A unique multi-county, multi-hospital collaborative effort among five hospitals and three Area Agencies on Aging (AAAs) has been awarded funding for the Medicare Community-Based Care Transitions Program (CCTP) sponsored by the Centers for Medicare and Medicaid Services (CMS). The program is designed to make the transition from the hospital to another setting as seamless as possible.

Targeting a 26-county region including rural Appalachia, this program will work to further reduce unnecessary hospital readmissions and achieve a reduction in Medicare costs. The target population for this program is Medicare Fee-for-Service patients with a primary diagnosis of Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease, Heart Failure or Pneumonia preparing for discharge.

This program focuses directly on improved patient outcomes such as reduced readmission to hospitals; decreased emergency department visits; discharging patients to the most appropriate, cost effective setting and streamlining access to quality long-term services and support.

“Care Transitions is a concept that was developed by the medical community which has proven to be effective,” said Pamela K. Matura, Executive Director of the Area Agency on Aging District 7 (AAA7). “Through trained coaches, we are able to help individuals develop skills that will assist them in managing the preventable causes that can lead them unnecessarily back to the hospital. I have personally experienced the confusion and different understanding of post-discharge instructions and medication management within a family when a loved one leaves the hospital, resulting in a re-admission very soon after discharge. This new program can help to prevent this occurrence. We are excited about the opportunity to partner with the three major health systems in our region to bring this important program to our 10-county area.”

Matura said the program offers a number of benefits.

“Obviously, there is an underlying goal to improve the discharge process to save Medicare dollars by reducing unnecessary hospital readmissions. But more importantly, the program goal is to empower people to be an active part of their health care, both in the present and for the future,” said Matura. “Care Transitions provides proven supports for individuals to help them heal and be at home — where most people say they would rather be. The Area Agencies on Aging are focused on connecting individuals to key home and community-based care resources.”

The participating Area Agencies on Aging include Buckeye Hills AAA8 — Southeast Ohio (Marietta) as the lead agency; AAA6 — Central Ohio (Columbus); and AAA7 — Southern Ohio (Rio Grande). The hospital partners include Fairfield Medical Center (Lancaster), Memorial Health Systems (Marietta), Adena Regional Medical Center (Chillicothe), Holzer Medical Center (Gallipolis) and Southern Ohio Medical Center (Portsmouth). The AAA7 is working directly with three of the hospitals including Adena, Holzer and Southern Ohio Medical Center.

“Holzer Health System has just completed the integration of its hospitals, clinics and long-term care facilities, so our patients will be able to move throughout our continuum of care with greater efficiency,” says T. Wayne Munro, MD, Chief Executive Officer of Holzer Health System. “Reconnecting our patients with their primary physicians after they have been discharged from the hospital will be strengthened by the opportunity to work with our local Area Agency on Aging district offices.”

AAA nurses and social workers will provide the evidence-based Care Transition Intervention (CTISM) program developed by Eric A. Coleman, MD, MPH, at the University of Colorado, Denver Health Science Center. This consumer-centered intervention tool is designed to improve quality and contain costs for individuals with complex care needs as they transition across settings specifically from the acute setting back to the home and community.

The Southern Ohio initiative was one of 23 sites announced by CMS in March 2012. CCTP currently includes more than 126 acute care hospitals across 30 sites to provide care transitions servi

ces for an estimated 223,172 Medicare beneficiaries in 19 states. CTTP was created by the Affordable Care Act.

Those interested in learning more can call toll-free at 1-800-582-7277 (TTY: 711). Information is also available on www.aaa7.org, or the Agency can be contacted through e-mail at info@aaa7.org. The Agency also has a Facebook page located at www.facebook.com/AreaAgencyOnAgingDistrict7

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