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. […]
For years, physicians and insurers have applied the so-called “improvement standard” for care rendered to Medicare beneficiaires, insisting that if the patient was not improving, he or she was ineligible for benefits. Taking on what she calls that “intractable myth”, Judith Stein, Executive Director of the Center for Medicare Advocacy, led a team that filed […]
A little knowledge can be a precious thing, especially when it comes to health care management. According to researcher Judith Hibbard, it’s an essential component of what she calls “patient activation”: having the knowledge, skills and confidence to manage your own health and health care. Hibbard has led the field in developing ways to measure […]
By Maryann Ingram I am caregiver to my live-in sister-in-law who has Korsakoffs and vascular dementia, with the onset at age 59. She lived in a nursing home for six years and then came to live with me last October under the “older adult living at home” waiver program. I take her to all of […]
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 […]
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 […]
by Phil Burgess There are two views of aging in America. In one, a 70 year-old woman drives another to the doctor. Across town, a later-life adult takes an even older neighbor to do her grocery shopping and then helps her bring the groceries into the house and makes sure they are properly stored. When […]
Older residents (with fee-for-service Medicare) of a four-county region around Rochester, New York, are likely to benefit from the innovative programs being launched by a community-based care transitions project (CCTP) in that region. The “Community-wide Care Transitions Intervention” is anchored by Lifespan of Greater Rochester, a non-profit organization funded mostly by the Administration on Aging. […]
Since 1995, Ohio-based Summa Health System and its partners have led a collaborative, the SAGE Project (Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project), which has worked to improve care for the state’s most vulnerable elders by integrating the aging network, and its social services, with health and medical care. The project aims to […]
Your 80-year-old mother, who can’t recognize you due to severe Alzheimer’s dementia, has developed pneumonia after being hospitalized with a broken hip. Her doctor has told you that she might pull through and that the medical team needs your input on how and where she will live after this episode: at home, or at a […]