evidence-based care transitions
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Evidence-Based Care Transitions. How Aging and Disability Resource Centers are Facilitating Partnerships across Health and Long Term Services and Support Systems. What is the Connection between Home and Community Based Services and Hospital Readmissions?. - PowerPoint PPT PresentationTRANSCRIPT
Evidence-Based Care TransitionsHow Aging and Disability Resource Centers are Facilitating Partnerships across Health and Long Term Services and Support Systems
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL [email protected] | WEB www.aoa.gov
What is the Connection between Home and Community Based
Services and Hospital Readmissions?
Home and Community Based Services
and Hospital Readmissions• In a study evaluating the home food
environment of hospital-discharged older adults, 1/3 of participants reported being unable to both shop and prepare meals
• Greater volume of attendant care, homemaking services and home-delivered meals is associated with lower risk of hospital admissions
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Anyanqu, Ucheoma O., Sharkey, Joseph R., Jackson, Robert T. (2011) Home Food Environment of Older Adults Transitioning From Hospital to Home. Journal of Nutrition in Gerontology and Geriatrics 30:105-121.Xu, Huiping et al. (2010) Volume of Home-and Community-Based Medicaid Waiver Services and Risk of Hospital Admissions. Journal of American Geriatric Society
2003-2006 AoA & CMS Framework Access to LTSS
2007 CMS RCSC Person Centered Planning
2008 CMS QIO14 Care Transition Sites
2008/2009 Person Centered HDM Program 2010 16
States EBCT Models
Strategies to Support Care Transitions
Community-based Care Transitions Program (Sec. 3026)
2011 System Integration Grants
ADRC Care Transitions Activity
Evidence Based Model States Implementing the Model
BOOST New Hampshire (*also implementing CTI℠)
BRIDGE Illinois
CTI℠California, Colorado, Connecticut, Florida, Maine,
Massachusetts, New Hampshire, New York, Rhode Island, Tennessee, Texas, Washington
GRACE Indiana
Guided Care® Maryland
TCM Pennsylvania
2010 Evidence Based Care Transitions Grant ProgramModels Implemented by Grantees (16 States)
AoA 2010 Evidence Based Care Transitions Programhttp://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx
• Center for Technology and Aging• 2010 competitive funding opportunity for Option D ADRC
Evidence Based Care Transitions Program grantees• Grant Awardees:
• California
• Indiana
• Rhode Island
• Texas
• Washington
Tech4Impact Diffusion Grants Program
Center for Technology and Aging Tech4Impact Diffusion Grants Program: Summary of the Program and the Awardeeshttp://www.techandaging.org/Tech4Impact_Grants_Abstracts.pdf
Engage Leadership
Cross Training
Staff Co-location
Written Protocols
Formalized Partnerships
Leverage Strengths
2010 Evidence Based Care Transitions Grant ProgramPartnership Strategies
Source: "Navigating Across Care Settings: Choices for Successful Transitions (NACS)"- Care Transitions Sample Flow Chart http://www.adrc-tae.org/tiki-index.php?page=allresources&catx=375&filter=grantee
Massachusetts Care Transitions Operating Model
Management Information System
Personalinterview
DecisionSupport
DevelopAction Plan
ConnectTo Services
Transportation
CDSMP/EBDP
HCBS
Nutrition
Housing
ParticipantIn Control
&Directing Services
No Wrong Door System
Coordinated Long Term Service and Support System
Continuous QualityImprovement
AoA Care Transitions Toolkit
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/Toolkit/index.aspx
Chapter One: Getting Started
Chapter Two: Taking Time to Plan
Chapter Three: Developing Effective Partnerships with Health Care Providers
Chapter Four: Measuring for Success
Chapter Five: Building Organizational Capacity
Chapter Six: Implementation and Day-to-Day Operations
Additional ResourcesAoA 2010 Evidence Based Care Transitions Programhttp://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx
The Aging Network and Care Transitions Toolkithttp://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx
ADRCs and Care Transitionshttp://www.adrc-tae.org/tiki-index.php?page=CareTransitions
Care Transitions Quality Improvement Organization Support Center http://www.cfmc.org/caretransitions/Default.htm
Care Transitions Quality Improvement Organization Support Center: Care Transitions Toolkit
http://www.cfmc.org/caretransitions/toolkit.htm
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Contact Information
Caroline RyanOffice of Program Innovation and
DemonstrationUS Administration on [email protected]
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV