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How the LTQA Meeting Tackled Care Transitions Through Innovative Communities

by Published On: Jun 06, 2012Updated On: Jun 28, 2012

I was honored to spend the first part of this week attending a joint meeting that served both as the Long-Term Quality Alliance's 3rd Innovative Communities Summit and the 2nd Learning and Action Network Event sponsored by the Integrating Care for Populations and Communities National Coordinating Center (ICPC NCC).

We helped found LTQA to address the important issue of improving transitions between hospitals, long-term care organizations and the community. LTQA does this by advancing best practices at the community level, promoting better care and outcomes while reducing costs, and raising the visibility of LTSS as part of the Health Care Spectrum. 

ICPC NCC helps Medicare Quality Improvement Organizations promote the same kind of seamless transitions between health care settings.

Several LeadingAge members attended the joint meeting, including a team from: 

Joanne Handy, CEO of Aging Services of California, also attended.

I co-facilitated a session with Amy Boutwell of Collaborative Healthcare Strategies that focused on 5 LeadingAge members who are fast becoming leaders in the innovative communities movement. 

Majd Alwan, LeadingAge SVP of technology and CAST executive director, described how these members are using technology-enabled care models to help reduce unnecessary hospital admissions and readmissions and to keep older adults healthy and independent. Their innovative thinking has made a tremendous difference in their communities and the lives of the people they serve. 

For example:

  • Cathedral Square Corporation (VT) has reduced hospital admissions by 19% among housing residents participating in its Support and Services at Home (SASH) program. We expect these improvements to continue now that SASH is helping housing residents share their electronic health data with community-based service providers through the Vermont Health Information Exchange.
  • An innovative continuing care at home program has helped Evangelical Homes of Michigan (EHM) expand the number of people it serves from 600 campus-based residents to 2,300 community-dwelling older adults. LifeChoices uses technology to connect older members living in their own homes with an EHM coach who helps them maintain their health and independence. 
  • A long-standing telehealth program at Jewish Home Lifecare (NY) has helped reduce hospital readmission rates from 16% to less than 5% for individuals with congestive heart failure and diabetes. The organization is now using that technology to help hospital partners get the same results. 
  • Lutheran Homes of Michigan (LHM) created a call center that uses key-word recognition software to support family caregivers. When caregivers call the Aging Enriched Network with an issue or concern, the software helps LHM identify and generate referrals to services that can help caregivers help their loved ones. 
  • A remote monitoring system is helping Volunteers of America (MN) identify and respond early to conditions that could send assisted living and nursing residents to the hospital if left untreated. In a pilot test of the system, the organization achieved a 75% reduction in billable interventions, including physician visits, hospital days, and emergency department visits, for monitored residents. 

Proceedings of the LTQA/ ICPC NCC meeting will be published in the next couple of months. 

I encourage all LeadingAge members to read them and share them with your executive teams and boards of directors.


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