Centers for Medicare and Medicaid Services (CMS) has announced that the NIC Area Agency on Aging is one of 35 new pilot sites nationwide selected to participate in the community-based Care Transitions Program (CCTP) aimed to reduce hospital readmissions. Bridging Care Across the Inland Northwest will help high-risk Medicare patients discharged from one of three local hospitals. Patients and their caregivers will work with a Care Transition Coach®, to learn self-management skills that will ensure their needs are met during the transition from hospital to home.
“This will provide an exciting opportunity to work in tandem with hospitals, physicians, clinics, and many others to enhance care for patients and reduce costs throughout an 11-county, Eastern Washington, Northern Idaho area,” said Nick Beamer, executive director of Aging and Long Term Care of Eastern Washington, who added he “welcomes working closely on this project with the Area Agency on Aging of North Idaho as well.”
“This effort truly is about the individual and how healthcare providers and community-based organizations working together can make a difference in people’s experience after a hospital stay,” said Pearl Bouchard, director of the NIC Area Agency on Aging.
Bridging Care uses the evidence-based Care Transitions Intervention®, which emphasizes four pillars of care: medication self-management, dynamic patient-centered record, follow-up with primary care provider, and knowledge of red flags.
The support of three participating hospitals has been critical to the success of the application. Providence Sacred Heart Medical Center, Providence Holy Family Hospital, and Kootenai Medical Center, all provided staff time and expertise to analyze data, develop the program, and put it into practice.
“Providence is privileged to be part of this ground breaking work. Our mission is to care for the poor and vulnerable through compassionate care and this collaboration helps to achieve this calling,” said Jeff Liles from Providence Medical Group.
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