Academic journal article Generations

Integrating Care Transitions into the Aging Services Network

Academic journal article Generations

Integrating Care Transitions into the Aging Services Network

Article excerpt

To effect smooth care transitions, the aging services network and health and social service delivery systems must collaborate

The Older Americans Act (OAA), which established the aging services network in 1965 and continues to dictate its organization, is considered the main instrument for organizing and delivering social and nutrition services to older adults and their caregivers. The OAA aging services network consists of fifty-six State Units on Aging, 629 Area Agencies on Aging (AAA), 246 tribal organizations, and more than 20,000 community-based provider organizations (Greenlee, 2012).

This network is charged with maximizing older adults' independence by promoting healthy living and developing a coordinated service delivery system. The delivery system includes providing a wide array of home- and community-based services like meals, in-home support services, care management, and transportation to older adults, people with disabilities, and caregivers. The experience and infrastructure of the aging network position it well to bridge the gap between the delivery of medical care and community-based supports and services, making it well-equipped to play a vital role in supporting care transitions.

Many aging network and care transition program goals intersect, and there are multiple opportunities to improve patient outcomes by working together. The shared goals include assuring safe transitions between care settings; preventing the health and emotional toll of hospital re-admissions; and reducing healthcare costs. Transition programs, supported by medical facilities and organizations serving older adults in their homes, provide a valuable link for patients between the two settings.

Since the OAA's passage, community-based agencies have developed the infrastructure and capacity to serve older adults in their homes and communities. Care transition services are designed to assist those at high risk for complications following hospitalization in safely returning home and avoiding re-admission. Often those most at risk for complications in transitioning from the hospital to home are also served by (or are potential clients of ) the aging network because OAA programs likewise target the most vulnerable. Community supports through the OAA are designed to provide the right supports at the right time in the most efficient manner.

The Aging Network's Related Experience

The aging services network has a strong history in delivering person-centered, communitybased care that also reduces healthcare expenditures through Aging and Disability Resource Centers (ADRC) and the Community Living program, the Money Follows the Person Initiative, and 1915(c) Medicaid waiver initiatives. All of these share the fundamental principles of providing effectively managed, person-centered service systems optimizing choice and independence; encouraging personal responsibility; and providing coordinated, high-quality home- and community-based care options. These principles are also embedded in effective care transition programs.

Many aging network agencies have increased the scope and number of evidence-based health and disease prevention programs through the OAA and other sources. Evidence-based care transition programs provide another vehicle for expanding capacity and promoting the health and well-being of individuals served. Care transition services provided through the aging services network allow for a smooth handoffof the patient from hospital discharge to home. Often following hospitalization, an individual has multiple new or recurring unmet needs that may have been heightened due to stress and illness. When the Atlanta Community Based Care Transitions Program examined the major root causes for re-admissions with partner hospitals, their findings were similar to others reported in the literature, including lack of self-management skills, medication errors, lack of follow-up care, lack of adequate community supports and services, and poor communication and care coordination (Gerontological Society of America, 2010). …

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