Category: Care Transitions

What They Did: CBOs and the Community-based Care Transitions Program

by Anne Montgomery Now that the health care sector is focusing on social determinants of health (SDOH) in older adults and actively pursuing partnerships with community-based organizations (CBOs) to meet a surging demand for supportive services, it’s an excellent time to ask: What do we already know from key demonstration programs in this space? Some

Continue reading

States Move to Chart a Path for More Reliable, Affordable LTSS

portraits of Anne Montgomery and Sarah Slocum

By Anne Montgomery and Sarah Slocum On May 4, 2018, the Michigan State Legislature voted to “just do it:” to assemble a group of experts to craft a blueprint for taking the Wolverine State deep into the future of Michigan’s age wave – all the way through the mid-21st century. Specifically, the language requires the

Continue reading

Interim Reports on Aggregating Care Plans to Manage Supportive Care Services for Elders

By Les Morgan The following reports were produced as deliverables for our project “Aggregating Care Plans to Manage Supportive Care Services for Elders” (Joanne Lynn, M.D., Principal Investigator).This project is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute. Dr. Lynn will provide a more detailed report on the project

Continue reading

Through a Glass Darkly: The Community-Based Care Transitions Program Evaluation

Photographs of Joanne Lynn and Sarah Slocum

By Joanne Lynn and Sarah Slocum “All models are wrong, but some are useful”. – George Box In late November, the Centers for Medicare and Medicaid Services (CMS) released an extensive evaluation of the Community-based Care Transitions Program (CCTP). (https://downloads.cms.gov/files/cmmi/cctp-final-eval-rpt.pdf) While the report has some useful points, the primary metrics used to measure performance –

Continue reading

Enhancing Collaboration and Communication Between Medical and Community Settings

Anne Montgomery portrait

By Anne Montgomery [as posted on the American Society on Aging (ASA) website] As evidence accumulates on how community-based organizations (CBO) can cost effectively meet the medical and long-term care needs of older adults through supportive services, the importance of linking multiple data streams across settings becomes clear. But until recently, policy barriers hampered effective

Continue reading

MediCaring Communities: Getting What We Want and Need in Frail Old Age at an Affordable Cost

MediCaring Communities: Getting What We Want and Need in Frail Old Age at an Affordable Cost Published June, 2016 194 pages, 6″ x 9″ (15.24 x 22.86 cm) ISBN-10: 1481266918 List Price $9.95 at Amazon.com Americans want a long life and most of us will get to live into our 80’s and beyond, but we

Continue reading

From Hospital to Home: The Missing Element in Discharge Planning

By Anne Montgomery and Leslie Fried of the National Council on Aging One of the hallmarks of the 21st century—increased longevity of the population—will increasingly drive federal, state, and local health care programs to focus on optimizing coordination of services across a range of medical care and community services providers. Discharge planning will play a

Continue reading

IMPACT’s Impact on Quality Measurement for Frail Elders

By Joanne Lynn What matters in the lives of frail elders centers on function — and understanding an elderly person’s course, over time, requires that everyone involved learn to measure functioning in the same way. That’s the core of the new Improved Medicare Post-Acute Care Transformation (IMPACT) Act, passed by Congress in September 2014. Within

Continue reading

The Case for Care Plans

Posted on behalf of Dr. Joanne Lynn Patients and policy makers must require that clinicians communicate effectively with patients and families, not only to plan for death but also to develop a care plan that guides healthcare services through to end of life. Discussing clinical circumstances and their probable course, understanding the patient’s goals and

Continue reading

Shaping Communities that Care for Frail Elders

Despite surveys that indicate our overwhelming preference to grow old and die in our own home, those among us who grow old and frail are more likely to live in many different settings. The likelihood that we will face old age encumbered by multiple complex health conditions makes it very likely that we will, at

Continue reading