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Coalition To Help Reduce Hospital Readmissions

The York County Area Agency on Aging (YCAAA) is partnering with local hospitals and other organizations to help reduce hospital readmissions as part of the federal government’s Community-based Care Transitions Program (CCTP).

Earlier this month, YCAAA, on behalf of the York/Adams Care Transition Coalition (YACTC), was accepted into CCTP by the Centers for Medicare & Medicaid Services (CMS). The Coalition includes the Adams County Office For Aging, Hanover Hospital, York Hospital, Gettysburg Hospital, Aligning Forces for Quality, and other providers across the region.

As part of the CCTP program, members of the Coalition will work together to provide added support to high-risk Medicare beneficiaries discharged from participating hospitals. The goal is to help reduce costly hospital readmissions by improving the transition to non-hospital settings. Costs associated with this program will be supported by funding made available through the Center for Medicare and Medicaid Services and will not rely on county or state resources.

According to CMS, nearly one in five Medicare patients discharged from a hospital —approximately 2.6 million seniors — is readmitted within 30 days, at a cost of over $26 billion every year.

During hospitalization, a trained Care Transitions Coach will meet with a patient or caregiver to assist them in becoming more active in their health care and having a better understanding of their illness. Following hospital discharge, the coach will make a home visit to support the transition process and will then provide ongoing follow-up by phone over a four-week period, as well as connecting them with home and community-based resources.

Local partnering hospitals express excitement as we incorporate this initiative and build upon other readmission programs already in place in the community.

“WellSpan is delighted to be part of another national innovation program that focuses on implementing new, local ways to improve the coordination of care for our patients between the hospital setting, physician office and community setting” said WellSpan Senior Vice President of Planning and Community Development, Maria L. Royce.

"Hanover Hospital is excited to be able to provide another level of care transition from acute hospitalization to home that will support Medicare beneficiary patients who struggle to manage multiple, co-morbid conditions in this time of socioeconomic challenges", added Janet Cutsail, (RN, BSN, CCM, CV-C) Director of Disease Management at Hanover Hospital.

The local York/Adams Community Transitions Coalition is one of 20 new sites across the United States announced in March 2013. To date, there are 102 sites nationwide providing care transitions services. CCTP was created by the Affordable Care Act.

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