CMS National Conference on Care Transitions December 3,

Atlanta Care Transitions Workgroup Build linkages and partnerships. Promote common understanding and the proven model – Coleman Care Transitions Model. Share best practices and results. Educate the medical and social service networks. Educate consumers and families. 2

Atlanta Area Agency on Aging One of 12 AAAs in Georgia; 635 in nation Serves as the ADRC and provides options counseling Provides care management services Provides support services to allow older adults to stay in the community Provides consumer outreach and education Forms part of the National Aging Network 3

The National Aging Network Congress Department of Health and Human Services Administration on Aging State Units on Aging Area Agencies on Aging Direct Service Providers Federal State Local State Advisory Councils Area Advisory Councils

Atlanta Care Transitions Framework 5 Home Health Community Services 4 Pillars Personal Health Record Red Flags Follow-Up Medication Adherence Linkage to Support Services

Information Services: Aging Disability and Resource Connection (ADRC) Incorporating care transitions protocols into options counseling Asking the right questions - Tell me what caused your hospitalization. -Tell me what you understand about your discharge plan. -Do you have a follow up appointment scheduled with your primary care doctor? Providing options for support services Providing educational materials Providing follow up Tracking calls Respond to 70,000 Calls per year 6

Care Management Incorporating care transitions protocols into care management Understanding the transition plan Using the Coleman coaching approach Complementing the transition plan with HCBS care plan Facilitating communication Tracking hospitalizations 7

Service Delivery System Support services provided under Older Americans Act, State and Local funding: Home delivered meals, in-home, caregiver support, transportation, adult daycare Services provided under the Medicaid Waiver Programs: Adult day health, skilled nursing, personal support services, home delivered meals, emergency response, alternative living 8

Service Delivery System Pilot Project Seven day pre-arranged support package: –Home delivered meals - 7 days –In-home support services - 6 hours –Transportation - 4 One way trips –Case management/coaching - 30 days MOU’s with 4 Hospitals Average cost: $ Readmission rate: 15.6% 9

Consumer Education Retired Professionals How to Navigate the Health Care System −How to prepare for a hospital stay and discharge −Importance of maintaining a Personal Health Record −Why complete a Georgia Advance Directive for Healthcare −Medication Management −Information about Medicare and related benefits Materials for Distribution In past year, 40 trained volunteers gave 77 presentations 10 Incorporating care transitions into the AAA Volunteer Outreach and Community Education Program

For more information, contact: Cathie Berger