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.
Community Care Transitions Program (CCTP)
33 Boston Post Road West - Marlborough, MA 01752 - Phone 508-573-7200