Recent federal and state initiatives have sought to reduce unnecessary readmissions to hospitals and focus on the frequent transitions of care between care settings that patients experience – especially older patients and those with multiple chronic conditions. There is growing recognition that most root causes of readmission are due to social needs, not clinical needs. Community-based organizations (CBOs) are often better equipped to address these needs than health systems. As a result, successful partnerships between traditional health care providers and organizations from the aging and disability networks, with expertise in social services, will become increasingly important to address the social needs that directly contribute to poor health, increase hospital readmissions and increase the cost of care.
This Success Story highlights the Eastern Virginia Care Transitions Partnership (EVCTP) – a formal community partnership of Area Agencies on Aging (AAAs), health systems, independent physicians’ groups and other public and private health and human services groups. This partnership has proven so successful in improving care and saving health care dollars, it is being expanded to provide a one contract, one-stop coalition for statewide services through the Virginia AAA Collaborative (VAAACares), beginning in July 2017.
Read the Success Story below to learn how enterprising AAA leaders came together to create a formidable and innovative CBO collaborative that is bringing value to health care in Virginia, improving the lives of the state’s most vulnerable, and building organizational capacity and sustainability.