Aug 232012

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 organizations in CCTP that is NOT an Area Agency on Aging. P2 is a non-profit regional health improvement collaborative, with origins as a Robert Wood Johnson-funded Aligning Forces for Quality community project. Through that work, it has engaged in various activities within eight counties in Western New York.

As Megan Havey, Manager of Care Transitions, explains, “P2 doesn’t provide direct services, but acts as a facilitator to members of the collaborative.” The scope of the project really called for coordination by a regionally based group, one that could work with and understand the diversity of partners, and that could offer the sort of infrastructure support that such a collaborative would require.

The collaborative is one of the largest in the CMS CCTP portfolio. It includes eight local community-based organizations (CBOs) and ten hospitals, and works with other community agencies, organizations, and foundations including the Health Foundation for Western & Central New York, IPRO (the QIO), the Alzheimer’s Association, local  hospice organizations, and county health departments.  The work sprawls across seven counties, with programs that aim to serve more than 2,600 patients annually. The diversity of participating organizations is remarkable, ranging from a 5-bed to a 150-plus-bed hospital.

Over the last six years, many of the participating organizations had participated in pilot programs to improve care transitions. Other groups had little experience, but, Havey says, “…were in a great position to be mentored by groups that had experience.” In building the application, IPRO helped with many tasks, such as creating templates to conduct the required root-cause analysis, analyzing admissions data, and convening partner organizations. Havey says that although IPRO has now “stepped back” from the project, P2 continues to solicit IPRO for technical assistance and support.

The application process was instructive, Havey says, in helping the partners to appreciate just how flexible the project would need to be. “Each county had a very different target population and model,” she says. “It was important  to be able to engage partners and obtain their buy in, but also to be realistic about what we could achieve in each county. We could not create a cookie cutter model.” All of the local CBOs and hospitals are using the Coleman model, the Care Transitions Intervention™, and are targeting Medicare Fee-For-Service patients.

Havey says that developing a web-based data platform that all partners could use has been an essential step. The platform had to accommodate the range of reporting capacity partners bring to the project. To that end, P2 worked with a software company to invest in and develop a platform all hospitals could use to enter data about eligible patients. The system operates within the context of the Care Transitions Intervention, and allows care managers to document data about home and hospital visits, as well as follow-up calls and evaluation information.

Havey notes special challenges in serving a rural population, particularly in terms of accessing care. There are not enough providers, she says, and transportation to get to them can be difficult. “Rural counties have very poor health outcomes, with many medically underserved areas and populations. Our goal is to reduce readmission rates with an intervention that leads to better health outcomes and improves quality of life.”

Key words: care transitions, CCTP, Section 3026, rural residents, readmissions

Jul 232012

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 and community-based long-term care services. Such integration is essential to bridging gaps between acute medical care and community-based care, enabling medical and social services providers to reach frail older adults living in the community with multiple chronic conditions, and to improve their quality of life. The SAGE project, which operates in the Akron, Ohio, metropolitan area, has managed to do just that. Results of the 17-year collaborative indicate that consumers, health care systems, health care providers, and payers have all benefited from the focus on integrating service delivery.

In the early 1990s, Summa Health System (SHS), an integrated not-for-profit health delivery system, had launched several projects aimed at improving care for frail elders. Summa comprises six community teaching hospitals with more than 2000 beds, as well as its own health plan, skilled home care, hospice, and a foundation. Summa’s insurance plan has 150,000 covered lives, including a Medicare Advantage Plan of 23,000.One of the projects being tested at Summa was the ACE (Acute Care for Elders) model, a model of hospital care delivery aimed at improving the functional status and clinical outcomes for hospitalized older adults. Recognizing that this model did not have the necessary patient connection in the outpatient setting, Summa realized it would need to expand its reach to elderly patients across the continuum of care. To this end, it created the Center for Senior Health (CSH), an outpatient consultative service that supports primary care providers by offering an interdisciplinary, comprehensive geriatric assessment; high-risk assessment; a geriatrics resource center; a clinical teaching center; inpatient geriatric consultation and outpatient consultation followup. The CSH attempts to treat and reach the whole patient by addressing acute and chronic medical needs, psychosocial needs, and family concerns. Despite the range of services provided, the CSH continued to be limited in its scope because it did not have access to patients in their homes, nor could it provide long-term case management. As a result, it began to rely increasingly on community-based long-term care agencies for this kind of information and management.

At about the same time, the Area Agency on Aging 10B, Inc. (AAA) found itself managing a growing number of consumers with functional decline, geriatric syndromes, and multiple chronic illnesses. The AAA, which serves more than 20,000 elders in Northeast Ohio, recognized that it needed to be better integrated with the acute medical sector if it were to achieve its goal of delaying and preventing nursing home admissions.

Leaders from Summa Health and the AAA recognized the challenges and deficits each one faced in providing continuity of care to patients/consumers, and began meeting to discuss how they could build a new, integrated model of care. They realized that they shared a common goal and vision to improve care for frail elders, and launched SAGE, which provided the organizational structure needed to effectively integrate their services. SAGE had no grants or funding, just a spirit of collaboration and cooperation, and a common desire to do more than just business as usual.

A SAGE task force was created comprised of staff from both organizations, including physicians, nurses, and social workers, as well as senior leaders, to promote communication, provide feedback, and create initiatives that linked the two. The group met monthly for two years, and now meets quarterly. Among its early objectives were the development of protocols to screen and identify at-risk older adults, to establish mechanisms for information sharing and resources, to identify gaps and duplication in service delivery, to locate a AAA case manager at the CSH, to educate staff from both organizations, to collect data and information, and to identify and address barriers to implementation.

Eventually SAGE created an RN care manager assessor program, in which placed an AAA assessor in the acute care hospital. The assessor works closely with the ACE team to identify hospitalized patients who can benefit from community-based programs, as well as patients who are eligible for PASSPORT, the state’s Medicaid waiver program. This was a new initiative for the AAA, which had traditionally conducted these assessments post-discharge, in the patient’s home. That assessment now occurs before the patient is even discharged from the hospital, thus helping to determine needs for  community based services and facilitating the process for eligibility  and approval for Medicaid long term care benefits.  This is beneficial because patients will typically receive Medicare covered services for skilled needs but long term care needs are not addressed as well and the Medicare skilled benefits are provided for only a limited time usually < 30 days.   Without the other supports this vulnerable population is at risk for poor health care access, emergency department visits and  hospital readmission. The AAA then assumes case management for the consumer, and offers periodic geriatric follow-up.

This program has facilitated improved capacity management for complex patients in the acute care hospital. It improved AAA communication with primary care and hospital staff, reducing repeat hospitalizations, ED visits, and nursing home placements. It improved outcomes for complex patients, and decreased discharges from PASSPORT to nursing homes. During the pilot period,  referrals to and enrollments in the PASSPORT program doubled.   The AAA was also successful in replicating this model at other hospital systems in the Northeastern Ohio AAA service area.  A more recent positive outcome  related to this collaboration work was the awarding for AAA 10b Inc. one of the first seven  Community Based Care Transitions projects from CMS/CMMI as part of the The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Patient Protection and  Affordable Care Act

In developing SAGE, several barriers had to be overcome, primarily those affecting leadership of the program, development of an effective multidisciplinary workgroup, and resources (in terms of staff time). The program can be adapted by other communities around the country, offering their acute medical system and community-based programs a way to align their services and collaborate in ways that better address the needs of frail older adults.

Key words: community collaboration, SAGE Project, ACE Units, CCTP, 3026, pilot programs

Feb 232012

CJE SeniorLife, a community-based organization that serves some 18,000 older adults annually, is among the first cohort of recipients for  Section 3026 or  Community-Based Care Transition Program (CCTP) funding from the Centers for Medicare and Medicaid. One of seven early awardees, CJE will anchor a project that includes three large hospitals in Northern Chicago, as well as long-term services and supports organizations that serve frail older adults.

Medicaring talked to Heather O’Donnell, JD, LLM, CPA, then CJE’s Director of Planning for Healthcare Reform. She said that the process that led to funding has been underway for more than a year, and began when the group first began to consider opportunities that were arising as a result of health care reform, and how it might further its effort to bridge gaps between social services and medical care.

CJE, which had already been involved in care transitions improvement efforts, began to reach out to hospitals in its community, approaching them to find out whether they would be interested in partnering for the CCTP opportunity. Ultimately, three hospitals were selected:  Northwestern Memorial Hospital (a major academic medical center), Provena-Resurrection Saint Joseph Hospital, and Provena-Resurrection Saint Francis Hospital. The team also includes Telligen, the Illinois Quality Improvement Organization and local Care Coordination Units. These state-run units, housed in communities throughout Illinois, address the needs of older adults who have complex, ongoing health care needs. Patients who have  diagnoses of pneumonia, congestive heart failure, or AMI are targeted, as well as those who have complex conditions or take multiple medications.

The intervention is based on Eric Coleman’s model, which focuses on coaching patients and families to improve self-management skills for chronic conditions and medication management. The 30-day intervention aims to help people access home and community-based services and features a follow-up home visit by a transitional care nurse within 72 hours of discharge. These nurses, who have participated in the Care Transitions Intervention training program, help patients and families to set 30-day post-discharge goals, and to make and keep followup appointments. In addition, CJE received foundation funding which is enabling it to include a social work intervention; very high risk patients are identified and receive followup with a social worker for six months post-discharge.

“We had to adapt the Coleman protocols,” says O’Donnell. “We felt that for some patients, those with chronic conditions and psychosocial problems, thirty-days of followup were insufficient. We found that about 10 percent of the patients in our program would need more support services. That part of our program is not covered by CMS but is funded with private foundation funds.”

O’Donnell says that pulling the project together has taken a great deal of collaboration with the participating hospitals—from the on-the-ground work of finding the right contact people to developing specific strategies for the intervention. “But we felt that this was a good fit with what the hospitals were already doing,” she said. “It is very exciting work, getting every provider in the community to think about the quality of care from the standpoint of preventing an unnecessary readmission.”

Asked whether there had been any problems in bridging the divide between social services agencies and hospitals, O’Donnell said there had not. “This isn’t about us versus them. This is about everybody pulling together and undertaking a new initiative that’s good for everybody—good for the hospital, the nursing home, the patient. It’s a new approach.”

CJE meets regularly with its partners at each participating hospital, although the three are some miles apart and there is no reason to try to pull them all into one meeting. Orchestrating such a meeting, O’Donnell said, would be quite difficult, given how busy people are, and how hard it is to accomplish specific tasks when so many people are involved. “We’ve found it’s more effective to address each hospital and their concerns and our strategies individually.” CJE is, however, convening quarterly meetings of participating nursing homes, at which it hopes participants will talk about their successes, challenges, and processes. CJE is also mindful of the role to be played through partnerships with its local AAA (Area Agency on Aging), which is in the midst of applying for separate CCTP funding. It is also keeping the Department of Health Care and Family Services apprised of its work.

The process of actually launching the program took several months of work with CMS to address questions and concerns and finalize a contract. The application, submitted in August, received final approval in November. The first wave of projects will begin in one hospital on March 1, with other hospitals launching in April and May; ultimately, the project anticipates serving some 2,700 people each year.  As O’Donnell notes, “It is a significant undertaking, and there are lots of details to be sorted out.”

She also noted that the relatively quick launch can be attributed in part to ongoing planning for implementation, addressing in advance issues that were likely to come up as the project rolled out. “We had these conversations internally and with hospitals before the application was even approved.” 

Key words: care transitions, Section 3026, CCTP, CMS, Coleman model, CJE


Feb 022012

The following blog originally appeared on the Altarum Institute Health Policy Forum blog at on Tuesday, January 31, 2012. It is co-authored by Janice Lynch Schuster and Joanne Lynn.

“Care transitions” is the new buzzword in efforts to improve health, improve care and reduce costs. It seems that everyone is jumping on the bandwagon, implementing evidence-based solutions to problems in transitions, launching new programs and applying for funds totaling half a billion dollars from the Centers for Medicare & Medicaid Services.

In November, CMS announced the first seven communities to receive funding under its new Community-Based Care Transition Program: Atlanta; Akron/Canton; Chicago; Southwest Ohio; Southern Maine; Maricopa County, Arizona; and the Merrimack Valley of Massachusetts. Communities have developed remarkable partnerships. Atlanta is involving six urban area hospitals serving 10 counties. Southwest Ohio has a team that includes university and community hospitals, as well as a health council and information technology groups covering areas in Ohio, Kentucky, and Indiana. Merrimack will serve patients in 33 cities or towns in the region. In short, it is an impressive array of organizations that recognize that no single organization or entity can solve the problems of care transitions. It will, in fact, take a village, one that relies on many organizations and stakeholders to craft solutions that match their community’s preferences, resources and priorities.

For those who are young and relatively healthy, care transitions (i.e., hospital discharges) may not seem like a big deal. New mothers are discharged to follow up appointments with their OB/GYNs and pediatricians and usually can enlist new fathers and grandparents to help out with the baby during the early weeks. People who have an injury or a planned surgery will be discharged with instructions to follow up with their primary care doctors, take prescribed medications and maybe participate in physical therapy. For patients who are generally young and healthy, connecting the dots and mapping out a few weeks of a new routine may present a challenge, but it is easy enough to adjust to and figure out.

It is not so for frail elders and their caregivers—people who are over the age of 65, often over the age of 85, who have functional and cognitive impairments, who rely on others for activities of daily living and whose resources limit where they can go and whom they can see. Indeed, the transition often proves so difficult or ineffective that at least 20 percent of Medicare beneficiaries will be rehospitalized within 30 days of their initial discharge.

Poor discharge planning can be calamitous. A recent Health Affairs article chronicled the horror that ensued when a terminally ill patient was discharged home to hospice, only to arrive there with insufficient oxygen and no morphine. He died, suffocating, within 20 hours. The hospice nurse showed up afterward, apologized, and instructed the family on how to flush the morphine that they had finally received.

Many models have been developed and are being tested, hoping to prevent or eliminate the kinds of errors just described. Massachusetts’ Brian Jack, M.D., leads Project RED (Re-engineering Discharge), a hospital-based program that relies on enhanced staff training and a video avatar to help guide patients and families through discharge and follow-up. Colorado’s Eric Coleman, M.D., has developed an approach that emphasizes self-care capability and teaches four pillars to a good care transition. The Transitional Care Model relies on a specially trained advance practice nurse to work with families through the discharge process. Other models have been proposed and are being studied.

In our early work for Altarum Institute’s Center for Elder Care and Advanced Illness, we have found it useful to leverage changes in five areas in order to improve the design and implementation of effective care transitions quickly: medication reconciliation, patient activation, hospital discharge process, matching patients and services and information flow. In coming months, the CECAI staff will blog about each of these issues, sharing what we learned in the course of surveying the literature and experience to date. We expect that the movement will mature toward working on right-sizing the service array, dealing with advance care planning and providing feedback to earlier providers from later providers to enable improvement. We will keep watch for these and others.

It is intriguing that the solutions now underway rely so heavily on coalition building. Public health has long relied on this strategy to solve problems and promote social changes around other issues, such as smoking cessation, impaired driving, breastfeeding, the built environment and substance abuse. There are several definitions of what makes for a coalition; according to Frances Dunn Butterfoss, “coalitions are interorganizational, cooperative, and synergistic working alliances.”(1) Coalitions appear to go through three critical but nonlinear developmental phases: formation, maintenance and institutionalization.(2) As the newly developed CCTP programs launch, they will need to learn how to organize, lead and sustain an effective coalition. Perhaps those with experience and research can help.

The usual transition of an older person from hospital to home appears to entail multiple errors. Probably no other point in patient flow has so many errors and so great a tolerance for them. The current work on improving care transitions is long overdue and likely to make major improvements in cost and quality. The social capital that this work creates by pushing all parts of the care system to communicate and learn to work in a coordinated way is important; it could be the lynchpin of a new era of cooperative endeavors to build continuity into the fragmented care system.


1. Butterfoss, F. D., Goodman, R.M. & Wandersman. (1993). Community coalitions for prevention and health promotion. Health Education Research Theory and Practice, 8(3), 315–330
2. Osmond, J. Community coalition action theory as a framework for partnership development. Originally retrieved from but which is now available from:

 Key words: care transitions, coalition building, frail elders, CCTP

Nov 282011

The Southwest Ohio Care Transitions Collaborative, one of 7 sites chosen by the Centers for Medicare and Medicaid for the first cohort of 3026 funding, had lots going for it as it pulled together a broad-based community health coalition and implemented strategies to reduce avoidable readmissions for older adults. The program brought to its application a coalition that included major community-based organizations, the local hospital association, and five hospitals serving the Greater Cincinnati area. It had demonstrated success with a care transitions pilot program based on the Coleman model, and it submitted an application to CMS that clearly explained the strategy behind its blended rate calculations. The Collaborative estimates that it will serve some 5,400 seniors each year, with a cost savings to Medicare of more than $1 million. The specific intervention is built directly on the Coleman model, with some modifications to account for local needs and experiences.

The application built on the success of a pilot project implemented at UC Health University Hospital, which showed that participants had a lower-than-average readmission rate, and that most patients were discharged to their home or other community setting, rather than to a skilled nursing facility. Sharon Fusco, Director of Business Results and Innovation for the Council on Aging of Southwestern Ohio, is optimistic that the care transitions intervention will significantly reduce readmissions among hospitalized Medicare beneficiaries with diagnoses that include pneumonia, heart failure, heart attack, or multiple chronic conditions.

In building the coalition, Fusco says the group aimed to be certain to include all of the organizations that could influence and affect patients’ lives; where the root cause analysis identified gaps in care, the coalition took care to find organizations that could fill them. As a result, the coalition now includes the Greater Cincinnati Health Council, which is the local hospital association; a health information and technology exchange organization; a program that helps to coordinate patient access to physicians; and a local mental health and recovery services board.

The Collaborative used its root cause analysis to identify gaps in care, and to consider strategies that would mitigate problems. So, for instance, as Fusco explained, the root cause analysis identified mental health issues as a significant barrier to patient involvement in discharge planning and follow-up. “We had to find a way to help these individuals, and to connect them to a mental health medical home,” Fusco explained. To that end, the mental health board was enlisted, and will play a critical role in assisting patients whose mental health problems present barriers to good care.

The analysis also found tremendous problems in medication reconciliation, a problem that affected more than 90% of patients in a pilot at University Hospital. In exploring this issue more deeply, the Collaborative found that many patients did not have relationships with or access to primary care physicians, a real barrier in trying to help hospitalized patients make and keep important follow-up appointments. To this end, the Collaborative involved a group that focuses on coordinating patient access to physicians.

In general, the Collaborative found that the Coleman Model matched most of its needs in responding to problems identified by the root cause analysis. The Council on Aging added a fifth pillar to the four pillars of the Coleman model home and community-based programs for which some patients might be eligible. Meals, home care assistance, and transportation are among the services these programs offer.

Fusco and  her colleague, Communications Director Laurie Petrie ,anticipate that the Collaborative will encounter some challenges in with regard to operations and technology  differences among participating hospitals (e.g., rural versus urban settings), and to the ramp-up of health information technology  systems. Fusco noted that one challenge will be “getting the right staff and the right tools to each hospital.” But she is confident in the Collaborative’s ability to overcome  these  barriers and deliver successful interventions.

Fusco offered some advice for other potential applicants. In particular, she advises that groups take time to explain in detail how they calculate their blended rate, “really spend time explaining the rate and what goes into it.” According to Fusco, the process of calculating the blended rate was difficult but critical. She said,  “The process of [pulling together this application] turned out to be a healthy exercise for us. Costing out all the inputs that go into providing this service was challenging and time consuming, but completely necessary. We built a cost model that allowed us to account for both fixed and variable costs. In the end, the process increased our learning, and we found it very beneficial.”

She advises other potential applicants to be thoughtful and meticulous as they develop their calculations. “You need to understand what your costs are, what’s fixed and what’s variable. Then you can plug in the numbers. But you have to think about everything that goes into serving a client—what does it cost you to actually run the intervention? Not just the face-to-face time with the client, but all of the rest of the costs.”

She also feels that the Collaborative’s application was stronger for having been reviewed and critiqued by external partners, individuals with no connection to the program being proposed. To that end, she said, consultations on aspects ranging from policy to cost were helpful.

Key words: care transitions, CCTP, Section 3026, award sites, community coalition, quality improvement

Nov 182011

CMS announced the first sites selected for the Community Based Care Transition Program. Please see the links below for the list of sites and an updated fact sheet. As noted above, we continue to accept applications and look forward to selecting additional sites in the near future.

The following overview of the selected sites offers a glimpse into where things will be happening as these programs launch. We at hope to interview leaders from many of these sites, and to gain their ideas and insights about what made for a successful application, and where others might learn from their work.

The Atlanta Community-Based Care Transitions Program (Atlanta CCTP), a collaborative partnership serving ten counties in the Atlanta region, including the Atlanta Regional Commission (an Area Agency on Aging), and six urban area hospitals: Emory University Hospital Midtown, Gwinnett Medical Center, Piedmont Hospital, Southern Regional Hospital, WellStar Cobb Hospital and WellStar Kennestone Hospital.

The Akron/Canton Area Agency on Aging (A/C AAA), working in partnership with 10 acute care hospitals located within, or geographically contiguous to, the A/C AAA service area in Ohio: Affinity Hospital, Aultman Hospital, and Mercy Medical Center in Stark County; Akron General Medical Center, Summa Akron City Hospital, Summa Saint Thomas Hospital, Summa Barberton Hospital, and Summa Western Reserve Hospital in Summit County; Robinson Memorial Hospital in Portage County; and Summa Wadsworth Rittman Hospital in Medina. County.

The Southwest Ohio Care Transitions Collaborative, serving the Cincinnati Metropolitan Statistical Area and surrounding counties in Kentucky, Indiana, and Ohio, including the Council on Aging of Southwestern Ohio, the Greater Cincinnati Health Council, HealthBridge, Health Care Access Now, Healthcare Improvement Collaborative, Hamilton County Mental Health and Recovery Services Board, Clinton Memorial Hospital, Jewish Hospital, Mercy Hospital Fairfield, The Christ Hospital, and UC Health University Hospital.

The Southern Maine Agency on Aging/Aging and Disability Resource Center (SMAA/ADRC), serving five counties in southern and mid-coast Maine in partnership with the Maine Medical Center Physician-Hospital Organization and five MaineHealth hospitals: Southern Maine Medical Center, Maine Medical Center, Mid-Coast Hospital, Miles Hospital, and PenBay Medical Center.

The Area Agency on Aging, Region One, serving Maricopa County in Arizona, in partnership with John C. Lincoln North Mountain Hospital, West Valley Hospital, Scottsdale Healthcare Osborn Medical Center, John C. Lincoln Deer Valley Hospital; APIPA, a Medicaid Acute Care Plan that serves dually-enrolled Medicare fee-for-service beneficiaries; and Sunwest Pharmacy.

 Elder Services of the Merrimack Valley, Inc., in partnership with Anna Jacques Hospital, Saints Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital, and serving 23 cities/towns in the Merrimack Valley of Massachusetts and ten bordering cities/towns in southern New Hampshire where patients using these hospitals also reside.

Council for Jewish Elderly (“CJE SeniorLife”) in Chicago, IL, partnering with Northwestern Memorial, Saint Joseph Hospital, and Saint Francis Hospital and working closely with Area Agencies on Aging in Chicago and suburbs, local Care Coordination Units (CCUs), and Illinois’ Quality Improvement Organization, IFMC.

Key words:  3026 funding, CCTP sites, care transitions, CMS

Nov 072011

The Centers for Medicare and Medicaid launched Community-Based Care Transitions Program, or CCTP, to reimburse the costs of coordinating care across settings. Dr. Joanne Lynn gives an overview of the program, and how it will work to engage community-based organizations engaged in improving care transitions.

Key words: Care transitions, Community-based care transitions, Section 3026, quality improvement, community-based organizations, Centers for Medicare and Medicaid

Oct 312011

Community-based coalitions are critical to improving care transitions. To this end, people working throughout the community, in a variety of settings, really need to work to get to know one another, understand each other’s systems, and develop solutions that will translate into effective services for the community. Dr. Joanne Lynn describes a few steps to take to launch such a coalition.

Key Words: care transitions, coalition building, Section 3026, Joanne Lynn

Oct 192011

In a factsheet from AARP’s Public Policy Institute, Lynn Feinberg and Allison M. Reamy  detail how provisions of the Affordable Care Act (ACA) will lead to better recognition of and support for family or informal caregivers. An estimated 40 million Americans are family caregivers, and provide everything from help with transportation to assistance with daily living. As boomers age, the need for caregivers will grow tremendously—but their numbers will note. It is essential that we have public policies that address the social, financial, and health care realities of people who are family caregivers. The ACA takes a step in that direction.

Noting that the ACA explicitly mentions the term “caregiver” 46 times, and “family caregiver” 11 times, the authors are hopeful in their analysis of how caregivers might benefit from programs and policies enacted under various sections of the Act. In particular, they note that progress will be made in four critical areas: engaging individuals and families in shared decision making and addressing family experience of care; recognizing caregivers as part of the care team in new models of care;  improving education and training not only of the health care workforce, but of family caregivers; and improving support for services at home and in the community.

Of special note is the effect Section 3026, the Community-Based Care Transitions Program, will affect the lives of caregivers.  Under that program, grantees will have to carry out at least one transitional care intervention, which could include any of several scenarios, with a focus on engaging beneficiaries and their caregivers. Topics might include discharge education, help to ensure timely follow-up appointments  with post-hospital and outpatient providers, self-management education, and help with comprehensive medication review and management.

The entire factsheet is available free and online at:

Key Words: care transitions, Section 3026, public policy, health care reform, ACA, family caregivers

Jul 292011

As a frontline hospital or nursing home professional, you may be feeling increasingly frustrated with the lack of support, community follow-up and caregiver training for your vulnerable patients and residents. Despite your hard work these complicating factors are likely to send your patient or resident back to the hospital. Your administrators may have suggested to you that you focus on reducing readmissions and avoidable hospitalizations, or you may have caught wind of all the efforts underway to improve care transitions. Whatever has brought you here, you certainly have a sense that you need to get started now on ways of caring for your patients and residents differently.

Chances are, you are not in this alone, and others throughout your organization share your concerns—and have ideas for how to improve them. To learn more about what others are doing to fix care transitions and reduce transfer trauma, you might contact your state’s quality improvement organization, which is now charged with coordinating state and local endeavors to improve care transitions. You can find your state’s organization at:  You might contact your Area Agency on Aging (for a national list, visit: to learn more about its plans to respond to funding opportunities created by the Community-Based Care Transition Program (CCTP), also referred to as Section 3026 funding. If you haven’t already, you might reach out to your colleagues or peers in other local organizations, and find out what they’ve been doing, or what they plan to do.

Once you have a feel for what is going on in your own community, you might join forces with others who are motivated to make improvement happen.  You might find that a team already exists, or you might lead the formation of one. You will need someone—usually, several people—who are willing to embody the vision, take some risks, forge coalitions, and anchor the work. You may want to gather data about the experience of people using your community’s health care systems. You may want to gather stories—they are  a powerful way to communicate about experiences, to share ideas, and to learn from one another.

More than anything, start the process! Find something that you can do to get things underway. Try your ideas and learn from what works. Encourage others to join you—generate and build on their enthusiasm, and your own. Things may change slowly—but notice that they do.

Refer to the “Get Started” module on improving care transitions, now available online at Based on the experiences of several organizations working to improve care, “Get Started” offers advice, guidance, and examples of how to build and sustain coalitions for this work, and how to measure progress. It is also full of real-life examples from other teams around the country. Build on their ideas and efforts as you develop your own. Be sure to check back often, as we plan to write frequently on issues surrounding care transitions, and on efforts to improve them. Or email us at [email protected]. We look forward to hearing from you.


Keywords: Care transitions, Section 3026, CCTP programs, avoidable hospitalizations, reduced readmissions