Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology

Established in 1977 as an Area Agency on Aging serving Northeastern Mas­sa­chusetts, Elder Services of Merrimack Valley supports the independence of old­er people and adults with disabilities living in the community by providing information and referrals to these residents and/or their caregivers. Elder Services of Merrimack Valley also oversees several programs to address behavioral health needs and promote alternatives to nursing home care.

The impetus for this program stemmed from Elder Services of Merri­mack Val­ley’s participation in the Com­munity-based Care Transition Program (CCTP), created through Section 3026 of the Affordable Care Act. This program supports promising service delivery models that reduce readmissions.

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an Area Agency on Aging in Northeastern Massachu­setts) visit recently discharged Medicare pa­tients in their homes and monitor them via telephone to identify and address de­clines in health status that increase the risk of readmission. Administered in partnership with area hospitals, the 4-week program begins with an inhospital visit to determine the risk of readmission.

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