A free program that has been proven to lower the chances of returning to the hospital means great news for caregivers and family members. If your loved one is in the hospital, or has been in the hospital in the last 30 days, they could be eligible for this free program and you owe it to them and yourself to be aware and use this new resource.

Prempaul Murrhee is the CCTP facilitator consulting for Elder Options and the Gainesville marketing liaison for Greystone Home Health Care.

Elder Options in partnership with UF Health and North Florida Regional Medical Center received funding through the Centers for Medicare and Medicaid (CMS) for a Community-based Care Transitions Program (CCTP). The program is funded for two years with the goal of reducing hospital readmission rates among all Medicare patients by 20%, addressing systemic readmission issues, and bridging the gap between patient, health providers and community services, says Murrhee. The good news is that if the goals of the program are met, the program will be funded for an additional three years.

“The programs also work with a coalition of agencies that include skilled nursing facilities (SNF), home health agencies, health departments and transportation providers among other agencies.” Murrhee said.

Community-based Care Transitions Program is unique in that it works with the patients to actively partake in their own health care needs.  To be eligible for the program, a patient must be enrolled in Medicare A and B, discharged from one of the partner hospitals, and reside in one of the following counties: Alachua, Bradford, Columbia, Hamilton, Lafayette, Marion, Putnam, Suwannee, Union, Dixie, Gilchrist or Levy. The program is based off the Care Transition Intervention model developed by Dr. Eric Coleman and involves a transition coach meeting with the patient in the hospital and at their home setting following a discharge from a hospital or skilled nursing facility.

During the visits, the transition coach empowers the patient to do the following:  develop a personal health record, perform a medication reconciliation to ensure the patient is able to acquire the needed meds, has a system in place to take their medications, discuss any red-flag warning signs of their condition and ensure there is appropriate follow up with the primary-care provider. The coach will also address any other issues that need attention such as help with accessing needed community based services or small equipment such as providing the patient with blood pressure cuffs, a scale and a pill organizer if they feel that it is needed.

“The program has been in operation for more than a year and has reduced readmissions among patients enrolled within the program by 50%,” Murrhee said.

For more information about CCTP or how to enroll, contact Elder Options at 1-800-963-5337.

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