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Evidence-Based Care Transitions

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?.

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Evidence-Based Care Transitions

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  1. Evidence-Based Care Transitions How 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 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL aoainfo@aoa.gov| WEB www.aoa.gov

  2. What is the Connection between Home and Community Based Services and Hospital Readmissions?

  3. Home and Community Based Servicesand Hospital Readmissions 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 U.S. Department of Health and Human Services, Administration on Aging, Washington DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL aoainfo@aoa.gov | WEB www.aoa.gov 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

  4. Strategies to Support Care Transitions 2011 System Integration Grants Community-based Care Transitions Program (Sec. 3026) 2008/2009 Person Centered HDM Program 2010 16 States EBCT Models 2007 CMS RCSC Person Centered Planning 2008 CMS QIO 14 Care Transition Sites 2003-2006 AoA & CMS Framework Access to LTSS

  5. ADRC Care Transitions Activity

  6. 2010 Evidence Based Care Transitions Grant Program Models Implemented by Grantees (16 States) AoA 2010 Evidence Based Care Transitions Program http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx

  7. Tech4Impact Diffusion Grants Program • 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 Center for Technology and Aging Tech4Impact Diffusion Grants Program: Summary of the Program and the Awardees http://www.techandaging.org/Tech4Impact_Grants_Abstracts.pdf

  8. 2010 Evidence Based Care Transitions Grant Program Partnership Strategies • Engage Leadership • Cross Training • Staff Co-location • Written Protocols • Formalized Partnerships • Leverage Strengths

  9. Massachusetts Care Transitions Operating Model 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

  10. Coordinated Long Term Service and Support System Continuous Quality Improvement Participant In Control & Directing Services Personal interview Decision Support No Wrong Door System Caregiver Supports Develop Action Plan Connect To Services Management Information System

  11. AoA Care Transitions Toolkit 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 http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/Toolkit/index.aspx U.S. Department of Health and Human Services, Administration on Aging, Washington DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL aoainfo@aoa.gov | WEB www.aoa.gov

  12. Additional Resources U.S. Department of Health and Human Services, Administration on Aging, Washington DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL aoainfo@aoa.gov | WEB www.aoa.gov AoA 2010 Evidence Based Care Transitions Program http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx The Aging Network and Care Transitions Toolkit http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx ADRCs and Care Transitions http://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

  13. Contact Information U.S. Department of Health and Human Services, Administration on Aging, Washington DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL aoainfo@aoa.gov | WEB www.aoa.gov Caroline Ryan Office of Program Innovation and Demonstration US Administration on Aging caroline.ryan@aoa.hhs.gov

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