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."

Contributing Presenters

Throughout this 65-page report, these respected thought leaders will share their unique approaches to care transition management that positively impact cost and engage the patient in their care decisions:

• Danielle Butin, director, northeast health services for Secure Horizons, United Healthcare;
• Diane Flanders, director of coordinated care systems at MassHealth, a unit that oversees the state’s integrated Medicare-Medicaid managed care programs, including Senior Care Options (SCO) and the Program of All-inclusive Care for the Elderly (PACE;
• Sarah Keenan, clinical liaison with Medica; and
• Gregg Lehman, PhD, president and chief executive officer of INSPIRIS at time of contribution and current president and CEO of Minneapolis-based Health Fitness Corp.

This report is based on 2006 and 2007 audio conferences on the importance of overseeing care transitions in the Medicare, Medicaid and dual-eligible populations.

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 Options Program
  • SCO Milestones
  • Managing a Merge of Medicaid and Medicare Services
  • SCO Highlights
  • How the Payment System Works
  • Senior Care Organizations
• Q&A: Ask the Experts
  • Predicting Inpatient Acute Utilization
  • Managing Fractures on an Outpatient Basis
  • Criteria for Identifying Pre-Hospice Patients
  • Acute Problem Management
  • Geriatric Depression Scale and Mini Mental Status Exams
  • Funding & Reimbursement
  • Interventions for Self-Management Disease Programs
  • Health Coaching in Pharmacy Outreach Programs
  • Determining the Frequency of Maintenance Visits
  • Components of the Home Visit
  • Training Transition Coaches
  • Training Nurse Practitioners
  • Care Transitions for the Dually Eligible
  • Care Transition Coordinator Caseload
  • Coordination Between Aging Programs
  • Following Geriatric Standards
  • Methods of Making Patient Contact
  • Integrating Utilization and Mental Health Responsibilities
  • The Long-Term Care Consultation Form
  • Recruiting Beneficiaries When Enrollment Is Voluntary
  • Keeping Nurse Case Managers Current
  • Dissecting the Central Enrollment Record
  • Avoiding Unnecessary ER Utilization
  • Nurse Care Managers and 24/7 Coverage
  • Nurse Case Manager Employment
• Glossary
• For More Information
• About the Presenters