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OFA launches care transitions program

September 19, 2012
Westfield Republican / Mayville Sentinel News

MAYVILLE - The Office for the Aging is launching the centers for Medicare and Medicaid services' Community-based Care Transitions Program in Chautauqua County.

"One of the biggest challenges seniors face after being released from the hospital is their inability to coordinate their ongoing care," Chautauqua County Executive Greg Edwards said. "The Community-based Care Transitions Program is all about the patients as it connects them with professionals to help them get the services they need to continue on the road to full recovery."

The Community-based Care Transitions Program, or 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 measurable savings to the Medicare program.

In March 2012, the Chautauqua County Office for the Aging was selected to participate in the program along with seven other community-based organizations and 10 hospitals that make up the Care Transitions of Western New York Coalition. The consortium is one of 47 organizations around the nation participating in CCTP and is led by P2 Collaborative of Western New York, a not-for-profit organization dedicated to educating and motivating people of Western New York to make healthy lifestyle changes.

"We are very pleased that our WNY consortium was selected to take part in this groundbreaking initiative," Executive Director of the P2 Collaborative of Western New York Shelley Hirshberg said. "The P2 Collaborative is thrilled to have this opportunity to work with its rural partners in seven of the eight counties of Western New York to improve quality of care for patients making the transition from hospital to home."

The Care Transitions of Western New York Coalition will serve more than 2,600 Medicare patients per year. All counties will provide care transitions services for Medicare fee-for-service patients who have been previously readmitted to the hospital within 30 days of a discharge. In addition, nine of the 10 participating hospitals will flag specific high readmission conditions like congestive heart failure, chronic obstructive pulmonary disease, pneumonia and diabetes.

"We are thrilled to be an essential component in this program and it is a perfect fit with the OFA's mission to keep seniors independent in their own homes for as long as possible," Chautauqua County Office for the Aging Director Dr. Mary Ann Spanos said. "We have already established this program with WCA Hospital and next week we are excited to launch our program with Brooks Memorial Hospital."

Spanos said that the NY Connects program is designed to link people to all available community resources and care transitions coaches, who may be staff from the OFA, Chautauqua County Health Network, Hospice or Willcare Inc. In addition to coaching services for the patient returning to home, OFA will provide information and connections to vital programs and services in the community that can help people through their recuperation period at home. Some of the services available are transportation to follow-up medical appointments, personal care services, adult day care, meals, health insurance counseling and wellness programs.

Other members of the Care Transitions of Western New York Coalition associated with Chautauqua County's transition services are Westfield Memorial Hospital, and the Community Concern of WNY Inc., in Derby and TLC Health Network Lake Shore Health Care Center in Irving.

For more information on the Care Transitions of Western New York Coalition, contact the P2 Collaborative of Western New York at 923-6572. For more information about transitions assistance in Chautauqua County, contact NY Connects at 753-4582, 661-7582 or 363-4582.



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