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Aging & Disability Resource Centers Evidence-Based Care Transitions
History and Background
AoA and CMS have funded several initiatives related to improving the coordination of care transitions, and the ADRC Evidence Based Care Transitions program is designed to build upon the activities of the past several years. Since AoA and CMS first began funding ADRC development in 2003, ADRCs have been working to assist individuals in “critical pathways,” which is defined as the times or places when people make important decisions about long-term care. This work included several innovative interventions to facilitate the hospital discharge process and to help nursing facility residents return to the community. Since that time, evidence-based models of person-centered care coordination have expanded around the country, and the 2009 AoA program announcement for ADRCs, “Empowering Individuals to Navigate Their Health and Long-Term Support Options,” emphasized reaching people during transitions from one care setting to another by naming “person-centered hospital discharge planning” as a key operational component of an ADRC.
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Purpose of the Program
The ADRC Evidence Based Care Transitions program supports state efforts to significantly strengthen the role of ADRCs in implementing evidence-based care transition models that meaningfully engage older adults and individuals with disabilities (and their informal caregivers). This grant opportunity is designed to promote the further development and enhancement of ADRC participation in evidence-based care transition models. This includes:
- Increasing the capacity of ADRCs’ current involvement in evidence-based care transition initiatives by expanding the reach of the ADRC efforts (e.g., adding additional staff, expanding an intervention to serve new populations, or expanding to additional sites).
- Strengthening the extent to which existing transitions programs leverage the assets of the ADRCs (e.g., to streamline access to public benefits, link individuals with community-based services and supports, and counsel individuals and their families on service options) among programs where ADRCs have a limited role currently.
- Informing AoA/CMS, other Federal agencies and Congress on national policy related to care transitions, hospital discharge planning, person-centered planning, and mechanisms to reduce unnecessary hospital re-admissions.
The 2010 ADRC Evidence Based Care Transitions Program Announcement included a special funding opportunity made available by The Center for Technology and Aging, with support from the SCAN Foundation, to support the use of assistive technologies in the Evidence-Based Care Transitions Programs funded through this program. For more information on this initiative, please refer to the program summary on the Center for Technology and Aging’s website
http://www.techandaging.org/Tech4Impact_Grants_Abstracts.pdf.
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Current Activities
In 2010, AoA issued awards to 16 states implementing six different evidence based care transition models. Please select a state below for project summaries.
When planning for discharge from the hospital or skilled nursing facility, consumers and caregivers often don’t know what support options are available or how to access community services. To address this important component of transitions, grantees have developed strategies to maintain fidelity to evidence based models while augmenting care transition services to include greater access to long term services and support in the community post-discharge.
The six evidence based care transition models being implemented by grantees include:
Better Outcomes for Older adults through Safe Transitions (BOOST)
Bridge program
Care Transitions InterventionSM
Geriatric Resources for Assessment and Care of Elders (GRACE)
Guided Care®
Transitional Care Model
For more information, please contact Caroline Ryan at caroline.ryan@aoa.hhs.gov.
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Program Evaluation
Grantees will develop and implement a formal evaluation of outcomes including providing:
- Evidence that the health and well being of individuals transitioning from different care settings has improved;
- Evidence that rates of hospital re-admissions have declined; and
- Documentation of efficiency and/or cost savings by the end of project
Other outcomes evaluated by grantees include:
- Access and use of Long Term Services and Supports
- Nursing Home Diversion
- Consumer and Stakeholder Satisfaction
- Physical Ability/Functional Status
- Achievement of Consumer Goals
- Medication Reconciliation
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Care Transitions Resources
AoA Resources
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Template for Developing Care Transitions Success Stories
This tool provides a basic framework to support the development of a brief story about a successful individual care transition experience. A good story confronts an urgent challenge faced by your community, taps into the values of community members to address the challenge and motivates individuals to take action in correction of that challenge.
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The Aging Network & Care Transitions Toolkit
This toolkit from AoA is targeted to organizations that are interested in learning more about how to prepare their organization for a role in care transitions. It includes case studies, resources and practical tools to assess your organization and plan for a care transition program.
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Webinar Series: Care Transitions
This initial series of webinars focuses on preparing the Aging Network to participate in the Community-based Care Transition Program demonstration (Sec. 3026 of the Affordable Care Act).
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Aging and Disability Resource Centers and Care Transitions
The U.S. Administration on Aging sponsors this Exchange to make information and resources available to states and community organizations.
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Health Reform Page
This site provides access to the latest information on health care reform and the opportunity to learn how it impacts seniors and those with disabilities in your community.
Other Resources
For Administrators
Care Transitions Quality Improvement Organization Support Center
The Care Transitions Quality Improvement Organization Support Center (QIOSC) assists Medicare Quality Improvement Organizations (QIOs) to promote seamless transitions from the hospital to home, skilled nursing care, or home health care.
Centers for Medicare and Medicaid Services: Community-based Care Transitions Program
The Community Based Care Transitions Program (CCTP) goals are; to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program. The demonstration will be conducted under the authority of section 3026 of the Affordable Care Act of 2010.
AHRQ Health Care Innovations Exchange
The Innovations Exchange helps you solve problems, improve health care quality, and reduce disparities.
Center for Medicare and Medicaid Innovation
The Innovation Center is a new engine for revitalizing and sustaining the Medicare, Medicaid and CHIP programs and ultimately to help to improve the healthcare system for all Americans. The Innovation Center, established by the Affordable Care Act, was given the flexibility and resources to rapidly test innovative care and payment models and scale up successful models.
AHRQ Care Coordination Measures Atlas
AHRQ’s new Care Coordination Measures Atlas lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination.
For Individuals and Families
Planning Ahead
Navigating the Health System: How to Avoid the Round-Trip Visit to the Hospital
AHRQ Director Carolyn Clancy, M.D., has prepared brief, easy-to-understand advice columns for consumers to help navigate the health care system.
AHRQ Patient Safety Network
Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient
This toolkit includes comprehensive information for patients and families to facilitate safe transitions from hospital to follow-up care.
Ask Medicare: Caregiver Information
AHRQ: Questions are the Answer
Clinicians, the Government, and many other groups are working hard to improve health care quality, but it's a team effort. You can improve your care and the care of your loved ones by taking an active role in your health care. Ask questions. Understand your condition. Evaluate your options.
AHRQ Patient Fact Sheet: 5 Steps to Safer Health Care
This fact sheet tells what you can do to get safer health care. It was developed by the U.S. Department of Health and Human Services in partnership with the American Hospital Association and the American Medical Association.
AHRQ Patient Fact Sheet: 20 Tips to Help Prevent Medical Errors
Government agencies, purchasers of group health care, and health care providers are working together to make the U.S. health care system safer for patients and the public. This fact sheet tells what you can do.
Preparing for Discharge
Your Discharge Planning Checklist: For patients and their caregivers preparing to leave a hospital, nursing home, or other health care setting
A checklist of important things you and your caregiver should know to prepare for discharge.
Taking Care of Myself: A Guide for When I Leave the Hospital
A guide for patients to help them care for themselves when they leave the hospital.
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| Last Modified: 10/4/2012 10:47:16 AM |
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