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Spotlight on Innovations and Achievements: Region VII AAA

Learn how this Michigan AAA provided much-needed services to Medicare beneficiaries and others by reconciling prescription and over-the-counter medications, linking clients with helpful home and community-based services such as home-delivered meals, chore services and personal care.

We're proud to highlight the award-winning work of the 2020 winners of n4a's Aging Innovations and Achievement Awards in this weekly spotlight feature. This week, we are focusing on Region VII Area Agency on Aging's Care Transitions: A Model of Acuity and Activation program. The agency was a 2020 Aging Innovations Award winner in the Healthy Aging category. The 2020 AIA Awards were made possible thanks to the support of Centene.
 
The Region VII Area Agency on Aging Community Care Transitions Initiative (CCTI) integrates an unskilled care transitions model with skilled medical care in the home to improve transitions of Medicare beneficiaries from in-patient hospital stays back to their homes. Region VII AAA Community Health Workers (CHWs) stationed in the hospital meet clients at their bedsides before discharge to arrange home visits, creating a smoother transition for clients. Having a knowledgeable, community-based point person within the hospital system is particularly beneficial to rural patients who live more than 60 miles from the hospital.
 
During each home visit, the CHW connects with a AAA-employed pharmacist for a medication reconciliation via video-conference software. Following each visit, the pharmacist sends a detailed letter summarizing the medication reconciliation to the client's health care providers and the client.
 
“The in-home portion of the program is imperative to recognize what is truly going on in the client's home. The pharmacist helps the client to grasp a better understanding of their medications and health conditions,” said Stacey Dudewicz, Project Manager at Region VII AAA.
 
Of the 500 clients served, 80 percent were seen by a provider within seven days of discharge. Combined with the pharmacist's medication reconciliation, this process reduced clients' readmission rate to three percent, compared to 18 percent for all hospital patients, allowing these individuals the opportunity to stay in their homes and become healthier in the place they are most comfortable. The University of Michigan College of Pharmacy is documenting the positive outcomes for a journal article.
 
“The participants have indicated that they are glad that this program offers further follow up after a hospitalization. Many have expressed that without this program, they are discharged from the hospital and the support ends there. This program helps to extend this assistance and helps ensure that there is continuity of care from hospitalization to primary care provider visits, ” Dudewicz added.
 
The Region VII AAA transitioned its CHWs to a mobile workforce with the CHWs conducting visits using video conferencing software or by making phone calls to continue to meet the needs of those discharged in its community. The pharmacist still reviews all medications with the client to ensure any issues and errors are addressed. Referrals to the program have continued to come in during the pandemic and the impact on client care remains evident.

Region VII AAA suggests that if an AAA was looking to start a similar program, they first seek out a hospital system to partner with that is motivated to help their patient population and interested in investing in the program. Appropriate staffing is needed to ensure the program can arrange meetings with clients that take place in a timely manner. A collaboration with a local health care organization helps ensure capacity-building, program sustainability and long-term funding.
 
To learn more about Region VII AAA's Care Transitions: A Model of Acuity and Activation program, contact Bob Brown, brownb@region7aaa.org.
 
For more information about the 2020 winners, see the press release and read the book of winners! To read about past winners and find other best practices for your agency to consider, visit our Best Practices page.

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