A consortium of 10 hospitals and eight community-based organizations led by the P2 Collaborative of Western New York has been selected among the first 30 organizations around the nation to participate in the Community-based Care Transitions Program (CCTP). The announcement was made by the Centers for Medicare and Medicaid Services (CMS) on March 14.
The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period.
CCTP's goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.
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After being discharged from the hospital, an Angola senior reviews her Personal Health Record with a Community Concern of WNY Care Transitions Specialist. The Personal Health Record is an important component of the Care Transitions Program.
Jerry Bartone, Comm-unity Concern's executive director, says that 10 regional hospitals and eight local community-based organizations in seven Western New York counties will align under the leadership of the P2 Collaborative to expand the Care Transitions Initiative that began at Community Concern in 2007. WNY Rural Care Transitions Consortium will build upon an existing regional effort around the Care Transitions Inter-vention, the evidence-based model developed by Dr. Eric Coleman, professor of medicine at the University of Colorado. Results of Community Concern's pilot program with Lake Shore Hospital, showed participants had 50 percent fewer hospital readmissions within 30 days.
Because the coaching will be provided by Area Offices for Aging or organizations, like Community Concern, affiliated with County agencies, this program will provide additional community resources, like home-delivered meals, where management saves public funds by helping clients remain independent in the lowest cost settings (home and assisted living).
"The program is voluntary," Bartone said. "So we hope seniors and the families will choose to enroll in the program. Hospitali-zation of a loved-one is traumatic enough to a patient and his or her family. This program will make the lives of seniors and their caregivers so much easier when they have this coaching specialist to guide them to a more successful recovery."
The Consortium will serve more than 2,600 Medicare patients per year.
The 10 participating hospitals include Brooks Memorial Hospital, TLC Health Network Lake Shore Health Care Center, Westfield Memorial Hosp-ital and WCA Hospital in Chautauqua County.
Also, the community-based organizations that will coordinate this effort include the Chautauqua County Office for the Aging, located in Mayville, Dunkirk and Jamestown.
About Community Concern of WNY Inc.
Community Concern is the leading provider of behavioral health and senior care management services in Southern Erie County and Northern Chautauqua County. For more information, visit www.communityconcern.org or call 947-5025.
