Coordinating Care Transitions for the Elderly and Dually Eligible: Fostering Self-Management and Reducing Readmissions

When the elderly and dually eligible populations transition from one healthcare setting to another, they frequently encounter gaps in care that negatively impact their health, unnecessarily prolong hospital stays and specialty care, and unduly increase the burden on caregivers and family. These care gaps are most likely to occur during transitions from primary to specialty care, from the emergency department to the surgical floor, from hospital to home or from in-patient to long-term care. Closing care transition gaps for these populations is the focus of "Coordinating Care Transitions for the Elderly and Dually Eligible: Fostering Self-Management and Reducing Readmissions." Table of Contents: Integrating Health Coaching Into a Comprehensive Health Management Effort : -Using Health Coaching to Better Manage Transitions and Improve Empowerment -Implementing Health Coaching Programs -Results of Health Coaching in Managed Care -Transition Coach Program -Advanced Illness and Coordinated Care Program (AICC) -Polypharmacy Transitions -Options for Living Self-Management Programs -Results of Living Self-Management Programs Managing Transitions for Medicare Patients to Avoid Costly Inpatient Admissions: -The Frail Elderly -- Growing Need, Growing Problem -The Changing Role of Family Caregivers -Ten Most Common Reasons for Hospitalizations Among the Elderly -How and When Breakdowns Occur -Acute Problem Management -Physician Relationship Management -Utilization and Cost Outcomes The Dually Eligible Medicare and Medicaid Population --A Care Coordination Perspective: -Program Eligibility Criteria -The Provider Payment Method -Defining Care Coordination and Its Functions -Working with Elderly Waiver Services -Transitions to Care and Healthcare Directives -Emergency Care Plans Prevent Surprises -Preventive Care for Seniors -Barriers to Compliance Senior Care Options (SCO)-- Bringing Medicare and MassHealth Together: -Objectives of the Senior Care Op