Southwest Virginia Patients Benefit from Care Transitions Program

June 27, 2013

June 27, 2013

​As one of the state’s 25 area agencies on aging, the Appalachian Agency for Senior Citizens (AASC) is committed to improving the lives of older residents in Southwest Virginia. Now, seniors will benefit from new services designed to prevent unnecessary hospitalizations.

AASC is among two Virginia organizations that have received funding through the Community Care Transitions Program (CCTP), led by the Centers for Medicare and Medicaid Innovation. With this added financial support, patients at risk for hospital readmissions will benefit from home visits focused on empowering those patients to manage their conditions.

According to  Regina Sayers, executive director of the agency, improving care transitions became a priority about two years ago. Staff participated in training programs to learn how to better support patients in their community. In addition, AASC joined VHQC’s Care Transitions Project to receive additional support through the Quality Improvement Organization (QIO) program.

Currently, the agency is working with four hospitals in the area. Patients are supported by three trained care transitions coaches who make home visits and provide telephone support. The agency assists between 20 and 25 individuals at any given time

By monitoring readmissions, AASC has identified a few key contributors to readmissions including:

  • Transportation challenges (i.e., unable to drive or access transportation)
  • High prescription drug costs
  • Limited access to primary care providers who accept Medicare patients
  • Health literacy issues

“We also encounter patients who do not have caregiver support at home. Without a caregiver, they do not pick up on red flags as quickly. By the time they arrive at the hospital, these patients are in bad shape,” Sayers said.

Initially, there was some confusion about the program and patients unsure about signing up. Appalachian worked with the hospitals and coaches to tweak the “script” used to describe the service. Now, care transitions coaches explain that they are working with the hospitals to help patients successfully transition home.

“Patients are very receptive to this program. They all accept our help and appreciate that we come to visit them at home,” Sayers said.

« Return to the News