MARIETTA — A unique multi-county, multi-hospital collaborative effort among five hospitals and three Area Agencies on Aging (AAA) has been awarded funding for the Medicare Community-Based Care Transitions Program (CCTP) sponsored by the Centers for Medicare and Medicaid Services (CMS).

The program, which includes Area Agency 8 of which Meigs County is a part, and Area Agency 7 of which Gallia County is a part, along with several counties in Area Agency 6, is designed to make the transition from the hospital to another setting as seamless as possible.

According to a release from AAA8 Director Rick Hindman of the Marietta office, which will serve as the lead agency in implementing the program, the program will target a 26-county region including rural Appalachia, and will work to further reduce unnecessary readmissions and achieve a reduction in Medicare costs.

The target population for this program is Medicare Fee-for-Service patients with a primary diagnosis of Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease, heart failure or pneumonia preparing for discharge.

Hindman said the program focuses directly on improved patient outcomes such as reduced readmission to hospitals; decreased emergency department visits; discharging patients to the most appropriate, cost effective setting and streamlining access to quality long-term services and support.

“Care Transitions is a program that has been tested in other states and proven to be effective in helping prevent folks from returning to the hospital,” he said. “We are very excited about the regional partnerships it is creating across health systems serving 26 counties.”

“There is an obvious underlying goal to reduce unnecessary hospital readmissions and reduce Medicare costs, but more importantly, the goal is to empower people to be an active part of their health care. It provides proven supports for individuals to help them heal and be at home — where most people say they would rather be. The Area Agencies on Aging are focused on connecting individuals to key home and community-based care resources,” added Hindman.

The participating Area Agencies on Aging include Buckeye Hills AAA8 – Southeast Ohio (Marietta) as the lead agency, AAA6 — Central Ohio (Columbus) and AAA7 – Southern Ohio (Rio Grande). The hospital partners include Fairfield Medical Center (Lancaster), Memorial Health Systems (Marietta), Adena Regional Medical Center (Chillicothe), Holzer Medical Center (Gallipolis) and the Southern Ohio Medical Center (Portsmouth). Learn more at http://www.areaagency8.org/services/care-transitions.

“Care Transitions supports patients in learning more about their illness and healthcare needs,” said Memorial Health System CEO Scott Cantley. “We encourage our patients to ask questions to better understand and manage their illnesses, to know their medications, and to communicate and follow up with their doctors.”

AAA nurses and social workers will provide the evidence-based Care Transition Intervention (CTISM) program developed by Eric A. Coleman, MD, MPH at the University of Colorado, Denver Health Science Center. This consumer-centered intervention tool is designed to improve quality and contain costs for individuals with complex care needs as they transition across settings specifically from the acute setting back to the home and community.