To limit hospital readmissions among local seniors, the Jefferson Area Board for Aging (JABA) and Well Virginia – UVA Health System’s Accountable Care Organization (ACO) – are partnering to improve patients’ transition after being released from the hospital.
Available to seniors in Charlottesville and the counties of Albemarle, Fluvanna, Greene, Louisa and Nelson, the Care Transitions Intervention model is designed to improve patients’ transition from the hospital to their homes, rehabilitation centers or long-term care facilities. The program uses coaches to develop and support patients’ confidence, self-advocacy and decision-making skills for their own health care, thus enabling them to remain at home and reducing the possibility of further hospitalizations.
ACOs such as Well Virginia are a new approach to health care in which physicians and other health care providers work as a team to better coordinate care and improve outcomes within a population of patients. To achieve their goals, ACO encourage caregivers to share more information about patients’ care. JABA is in its 41st year of providing a wide variety of assistance and resources for seniors in the greater Charlottesville area.
“We want to do everything possible to avoid readmitting patients to the hospital,” says Dr. Dan McCarter, Medical Director of Well Virginia. “Our goal in teaming with JABA is to help patients successfully transition home from the hospital, help them recuperate as quickly as possible and reduce the chances that the patient may need to be hospitalized again.”
“The partnership between Well Virginia and JABA demonstrates how health care brings together the excellent medical care at the University of Virginia Medical Center and the excellent community resources at JABA,” says Marta Keane, CEO of JABA. “The partnership also strengthens a shared commitment to providing more compassionate, coordinated care and reducing health care costs.”
In addition, the partnership advances JABA’s strong commitment to supporting “aging in place” by assisting patients (and their caregivers) in learning self-advocacy skills that will allow them to take charge of their own health care.
The Care Transitions program provides each patient with a coach, who will assist in facilitating a safe transition into the home or other discharge environment. The coach will provide a variety of assistance, from understanding the patient’s diagnosis, symptoms, and medications, to identifying areas that may require other community resources, and refer the patient to JABA for further information and assistance.
Unlike JABA’s Options Counselors, who seek to solve a variety of client problems associated with aging, Care Transitions Coaches take a “teach a person to fish” approach to managing health care issues, so that clients have the skills and knowledge of available resources to care for themselves.
For more on the national efforts regarding Care Transition, please visit CMS.gov. To learn more about JABA’s Care Transitions program visit www.jabacares.org or contact Ginger Dillard , JABA, Director of Advocacy Services, at 434-817-3556.
