1-800-582-7277 (TTY: 711)

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Hospital Care Transitions Program

In 2012, the Southern Ohio Community Care Transitions Project (CCTP) was approved by the Centers for Medicare and Medicaid Services (CMS) and joined similar projects nationwide providing care transition services to Medicare Fee-for-Service (FFS) patients in our area.

The project, which is made available through the Affordable Care Act and has been recognized nationally as a top performer, is a collaboration between three Area Agencies on Aging (AAA) - District 7 in Rio Grande, District 6 in Columbus, and District 8 in Marietta.  Five area hospitals also partner in this project including Adena Medical Center in Chillicothe, Fairfield Medical Center in Lancaster, Holzer Health System in Gallipolis, Marietta Memorial Hospital in Marietta, and Southern Ohio Medical Center in Portsmouth.

The Area Agency on Aging District 7 utilizes the Coleman Model, designed to follow patients through their transition from hospital to home for the first 30 days post-discharge. The patient is identified at the hospital and visited by a Care Transitions Coach (one of the AAA employees) to discuss discharge planning, be introduced to their own personal health record, and schedule a home visit shortly after discharge. The ultimate goal is to help prevent readmission back to the hospital. The intervention is designed to empower individuals to be more knowledgeable and involved in their healthcare and treatment.

For more information about the Community Care Transitions Project, call the AAA7 at 1-800-582-7277.