Tag: 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

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

No Disrespect: How Family Caregivers Can Improve Care Transitions

By Anne Montgomery Leaning into the podium at the Graduate Center of the City University of New York on May 14, Judy Feder, professor of public policy at Georgetown University, is poised and intent.  She is speaking to a room full of researchers, advocates and academics who are hoping to ignite a national conversation about

Continue reading

JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations

By Dr. Joanne Lynn The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises

Continue reading

Readmissions Count: Should CMS Revise Its Calculations?

by Dr.  Joanne Lynn When community coalitions apply for funding from the Community-Based Care Transitions program of the Centers for Medicare and Medicaid (CMS), they have to show that they will reduce hospital readmissions by 20% and will save money for Medicare. Funding recipients will be held to those two outcomes in evaluating the contract.

Continue reading

Reaching Rural Residents: Improving Care Transitions in Western New York State

The P2 Collaborative of Western New York [name was changed to Population Health Collaborative in 2017] represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is unique in its focus on a very rural area of Western New York, and is unusual in that it is one of a few  community-based

Continue reading

SAGE: Bridging the Divide between Acute Medical Care and Social Services in Northeast Ohio

By Dr. Kyle Allen and Susan Hazelett The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995. SAGE  provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services

Continue reading