Timely home visits following patients' discharge from the hospital offer patients tools and support that promote self-management and reduce the likelihood of readmission to the hospital.
In this report, transitional care business manager at the Council on Aging (COA) Southwestern Ohio, describes her organization's home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.
Cognizant that poorly executed care transitions lead to poor clinical outcomes, dissatisfaction among patients, and the inappropriate use of hospital emergency and post-acute services, COA developed the home visits intervention, in which field coaches conduct post-discharge visits to patients at home and/or within skilled nursing facilities (SNFs).
Home visits are a key feature of COA's care transition management initiative, modeled on the evidence-based Eric Coleman Care Transitions Intervention ® (CTI)®. With its focus on community support, the COA care transitions program is designed to help patients access the most appropriate post-acute medical care and home community-based services to avoid more costly nursing home placements when unnecessary.
COA is a member of the Southwestern Ohio Community Care Transitions Collaborative, the second program in the nation accepted into CMS's Community-Based Care Transitions Program (CCTP). The goals of the CMS CCTP are to: improve transitions of beneficiaries from the inpatient hospital setting to other care settings; improve quality of care; reduce readmissions for high-risk beneficiaries; and document measurable savings to the Medicare program.
This special report provides the following details:
In an expanded Q & A section, a host of details on the tools and hallmarks of the program is provided, including coach skill sets, coping with patient pushback, coach-home visit ratios, and more.
Table of Contents
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