Community Care Transition Initiative
This project addressed the often chaotic transition older adults face as they go home after admission to the hospital. In many cases, follow-up medical care, medication management, and in-home social services are all needed to ensure a smooth and successful return home.
Without proper planning, access to ongoing care, and navigation support, older adults can experience poorer health outcomes, diminished quality of life, and readmission to the hospital following discharge.
Solution
This project developed a long-standing partnership between Ascension St. Mary’s and the Region VII Area Agency on Aging (AAA) to ensure older adults in Michigan’s Saginaw Bay region received the appropriate medical care and supportive services while recovering at home following an admission to the hospital. This model successfully integrated home services provided by the AAA and ongoing care delivered by the health care partners to improve health outcomes for older adults, while also reducing costs. It also engaged a pharmacist to provide support in the home setting to decrease medication issues, which can be a significant driver of readmissions. As a result of the pilot’s success, the model has been integrated into Ascension’s care management program, extending the impact of the grant to provide lasting benefits to older adults receiving care at the hospital.
Key Outcomes
- The pilot program led to a reduction in same-cause hospital readmissions from 15 percent to 3 percent.
- More than 80 percent of participating patients visited their primary care physician to access evaluation and follow-up care within seven days of discharge.
- The program is now embedded in the health system and has expanded to other hospital system sites.
- This project was a catalyst for a broader Special Projects and Emerging Ideas grant with MDHHS to develop a care transition service definition, which opened up state and federal funding to replicate these services. There are currently five related programs being developed in locations around the state.
Project Summary
Region VII Area on Aging was awarded a grant for the Community Care Transition Initiative, a program that engages Community Health Workers, a pharmacist, and a patient’s primary care provider around an integrated care transition plan as they move from hospital to home. In addition to a comprehensive suite of services, the model offers opportunities for ongoing evaluation of the older adult’s health status and evolving needs, while promoting cooperation and communication among the patient and their care providers.
One unique element of the project is the deployment of a pharmacist to provide medication management support in the home. This feature introduced an added layer of critical expertise not included in previous care transition models.
The project’s strong outcomes have led to continued investment from the pilot program hospital, as well as funding commitments from Michigan’s State Unit on Aging to expand the program to five more regional Area Agencies on Aging. Additional hospitals, as well as federal policymakers and peers in other states, have also moved toward replicating the model in the near future.
“The Health Fund grant was like the seed money, and the hospitals have seen the value of the model and fund it themselves,” said Bob Brown, CEO, Region VII Area Agency on Aging. “The program has resulted directly in improvements that are benefitting the hospitals, as well as the people receiving care.”
Details
Lead Organization
Region VII Area Agency on Aging
Partner Organization
Ascension St. Mary’s
Location
Saginaw Bay Region
Year
2017
Duration
Three years
Total Budget
$660,000
Health Fund Investment
$500,000
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