1. Care Transitions Intensive

2. 2 Agenda Open Session (8:00 – 10:30) AoA Introduction/Overview Cross Cultural Strategies for Strengthening the Relationship between Hospital and Community Systems. Ed Walsh, MSW Director Senior Service Systems County of Riverside Riverside, California Robert J. Schreiber MD Physician-in-Chief Clinical Instructor in Medicine, Harvard Medical School Hebrew SeniorLife

3. 3 Agenda (continued) Break Interactive Care Transitions Workshop Closed Session for 2010 Option D ADRC Evidence Based Care Transition Grantees (10:45-12:30)

4. 4 Care Transition Opportunities Community-based care transitions program (Sec. 3026). Provides funding to hospitals and community-based entities that furnish evidence-based care transition services to Medicare beneficiaries at high risk for readmission. For entities eligible to participate in community-based care transitions program, the law gives priority to applicants that “participate in a program administered by the Administration on Aging to provide concurrent care transitions interventions with multiple hospitals and practitioners.”

5. Perspective of Person AAA/ADRC Hospital Nursing Facility Primary Care Physician Rehab Center

6. Service Plan/Care Plan AAA’s/ADRC’s Connect People To Needed Services

7. ADRC/AAA Core Functions System Development ADRC/AAA Intake Assessment Care Management Enrollment Connect to Service Provider VD-HCBS Assessment Care Plan FMS Service Connection Care Transitions Assessment—Environmental too Medication Reconciliation Care Plan Service Connection—CDSMP, Transportation Packaging Core Functions

8. 8 Care Transitions/Coordination HCBSHospital Nursing Home Physician Practice Assisted Living Pharmacy “Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities...“ Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. (2003)

9. 9 2003-2006 AoA & CMS Framework Access to LTSS 2007 CMS RCSC Person Centered Planning 2008 CMS QIO 14 Care Transition Sites 2008/2009 Person Centered HDM 2010 16 States EBCT Models Strategies to Support Care Transitions

10. 10

11. 11 Care Transition Resources AoA’s Aging and Disability Resource Centers and care transitions http://www.adrc-tae.org/tiki-index.php?page=CareTransitions AoA Care Transitions Workgroup http://www.adrc-tae.org/tiki-index.php?page=PreviousCTWorkGroupCalls To join the Care Transitions Workgroup, please email caroline.ryan@aoa.hhs.gov

12. 12 Care Transition Resources CMS Community-based Care Transitions Program http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS 1239313 Care Transitions Quality Improvement Organization Support Center http://www.cfmc.org/caretransitions/Default.htm

13. 13 AoA Affordable Care Act Webinars Care Transitions: What Do These Programs Look Like? And How Can the Aging Network Play a Role? Care Transitions: Making the Programmatic Case  Care Transitions: Building the Business Case http://www.aoa.gov/Aging_Statistics/Health_care_refo rm.aspxhttp://www.aoa.gov/Aging_Statistics/Health_care_refo rm.aspx (under Updates section)

14. 14 Affordable Care Act Resources AoA’s Health Reform web page http://www.aoa.gov/Aging_Statistics/Health_care_reform.aspx Department of Health and Human Services’ health care reform web site http://www.healthcare.gov Affordable Care Act text and related information http://www.thomas.gov/cgi- bin/bdquery/D?d111:1:./temp/~bdsYKv::|/home/LegislativeData. php?n=BSS;c=111|

15. Cross Cultural Strategies for Strengthening the Relationship between Hospital and Community Systems. 15 Robert J. Schreiber MD Physician-in-Chief Clinical Instructor in Medicine, Harvard Medical School Hebrew SeniorLife Ed Walsh, MSW Director Senior Service Systems County of Riverside Riverside, California

16. 10 Minute Break 16

17. Interactive Care Transitions Workshop 17

18. 18 Closed Door 2010 Option D ADRC Evidence Based Care Transition Grantee Meeting

19. 19 Agenda Introductions Review Grant Goals/Timeline Case Studies/PPT slides Care Transitions Toolkit –What would you want in it? –What would you include? Training

20. 20 Introductions Name Organization you are representing Evidence based care transitions model Identify biggest care transitions challenge Identify biggest breakthrough Identify one question you would like answered by the end of this meeting

21. 21 Option D Grant Goals ADRCs integrate medical and social service systems through implementation of EB CT models –Help older individuals and those with disabilities remain in their own homes and communities after a hospital, rehabilitation, or skilled nursing facility visit Demonstrate the meaningful role of community-based organizations in care transitions

22. Demonstrate the added benefits obtained by leveraging assets of ADRC’s (streamline access to public benefits, linkage to HCBS etc) Inform development of national policy related to care transitions, hospital discharge planning, person- centered planning, and mechanisms to reduce unnecessary readmission 22 Option D Grant Goals (continued)

23. 23 Grant Awarded Finalize Process Serve Clients Collect and Evaluate Data Final Report Negotiate and execute agreements with medical and social support partners Develop operational structure Hire and train staff in EB CT model Map and submit evaluation plan Draw down funds Implement Model Evaluate according to plan Submit CT information in SART every six months as part of regular ADRC reporting process Maintain relationships with medical and social support partners Submit Final Report 3 months after the grant period ends Report includes lessons learned and evaluation findings