During the course of an illness, a patient might receive care from a primary care physician or specialist, then transition to a different physician and nursing team when admitted to the hospital, then move to another care team at a skilled nursing facility. Finally, the patient might return home, receiving care from a visiting nurse. Each of these shifts between care providers and settings is a care transition.
Attending the training from the Area Agency on Aging District 7 (AAA7) were Linda Green, RN, from the AAA7’s Portsmouth Office; Connie Montgomery, RN, from the AAA7’s Rio Grande Office; and Joy Polley, RN, from the AAA7’s Waverly Office. All three are now certified Care Transition coaches.
By completing the Care Transitions Intervention Training, AAA7 staff members are prepared to coach consumers to successfully transition between care settings, ensuring them a better quality of life and saving money by reducing costly avoidable hospital readmissions. A transition and therefore the potential for an intervention occurs anytime a patient transfers between health care providers and settings as their condition and care needs change during an illness. Care transitions intervention work is not a new concept for the Area Agencies on Aging; however, it is receiving increasing attention under the Affordable Care Act.
The aim of the Care Transitions Program is to:
Empower patients and families;
Increase communication and exchanges of information among healthcare providers;
Enhance the ability of health information technology to promote health information exchange across care settings;
Implement system level interventions to improve quality and safety;
Develop performance measures and public reporting mechanisms; and
Gather practice data to influence health policy at the national level.
Currently, the Area Agency on Aging District 7 is working with partner organizations on care transitions to provide a smoother process for patients and their families upon discharge from the hospital. At present, the AAA7 has partnerships with Adena Health System in Chillicothe, Holzer Medical Center in Gallipolis, and Southern Ohio Medical Center in Portsmouth. In addition, the Agency works with a number of physicians, home health agencies, and nursing facilities throughout its ten-county district to achieve the aim of the Care Transitions Program in improving the health and well-being of individuals in our communities.
More information about the Care Transitions Program is available at www.caretransitions.org.