Adult Family CareArea Agency on AgingCaregiver SupportElder Community CareElder Housing OptionsHealthy Living
Home Care ProgramICO OneCareLGBT InitiativeMoney ManagementNutritionOmbudsman
Options CounselingPersonal Care AttendantProtective ServicesSenior Care Options

Changes in health care - how we access it, how we pay for it - is in the news every day. 
The Patient Protection and Affordable Care Act (PPACA - commonly known as the Health Care Reform law), contains a number of provisions that are intended to significantly increase the link between the Medicare payments to providers and the quality of the services furnished and patient outcomes. Medicare beneficiaries are worried about how this will affect them.

Did you know …..?

•   6.2% of beneficiaries discharged from the hospital were 
     readmitted within 7 days
•   11.3% were readmitted within 15 days
•   17.6% were readmitted within 30 days
•   Readmissions within 30 days accounted for $15 billion
    in Medicare spending (2005)

A new program created by health care reform – the Community Care Transitions Program  
(CCTP) – was designed to improve the care of Medicare beneficiaries at high risk for 
readmission to the hospital. BayPath Elder Services will be working with Vanguard Health, 
Elder Services of Worcester Area and UMass Memorial Health to provide care transitions 
services to eligible beneficiaries in 90 communities. BayPath and our partners will be known as the Central Mass/MetroWest Transitions in Care Collaborative.  

BayPath Elder Services has certified Coleman Coaches™ on staff to provide care transitions interventions to eligible older adults. The Coleman Care Transition Intervention    program is evidence-based and widely employed throughout the United States. Care transition coaches support patients by providing specific tools and teaching self-management skills to ensure the needs of the patient are met during transitions across settings, such as hospital to home.
 If you would like more information
Please contact Gwen Blumberg at 508-573-7200 ext 238
The foundation of the Coleman Care Transitions Intervention    is 4 pillars or domains, 
each providing a pivotal component of the process.  

     •   Medication management ensures the patient is knowledgeable about 
         medications and has a medication management system

​     •   The patient utilizes a Personal Health Record to facilitate communication
         and ensure continuity of care plan across providers and settings

​     •   The patient schedules and completes a follow-up visit with their 
          Primary Care Provider or Specialty and is empowered to be an active 
          participant in these interactions

     •   Knowledge and understanding of red flags is critical for the patient 
         to recognize that their condition is worsening and understand how to respond

The Central Mass/MetroWest Transitions in Care Collaborative 
is one of four programs in Massachusetts and one of forty-seven nationally.
BayPath serves the following towns:

Ashland, Dover, Framingham, Holliston, Hopkinton, Hudson, Marlborough, Natick, 
Northborough, Sherborn, Southborough, Sudbury, Wayland, and Westborough.
SM
SM
Community Care Transitions Program (CCTP)

Home
Our Services
Aging News
Employment
Donations
Who We Are
Under 60
Resources
Volunteers
Contact Us

  33 Boston Post Road West - Marlborough, MA 01752 - Phone 508-573-7200
© 2013 BayPath Elder Services, Inc. | All Rights Reserved | Contact Webmaster
HomeOur ServicesContact UsDonationsPrivacy