Virginia Finds Better Ways to Transition Patients From the Hospital to Their Homes

*This blog is cross-posted on America’s Health Insurance Plans (AHIP) blog HERE.  As part of its outreach to and collaboration with the health care community, the Aging and Disability Business Institute worked with AHIP to develop this blog and create a conference session on the Virginia AAA partnership described below for AHIP’s Conference on Dual Eligibles.* 


Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million older adults—are readmitted within 30 days, at a cost of over $26 billion a year. Implementing appropriate interventions necessary for reducing readmissions can go a long way to reduce costs and improve quality of care. An innovative program in eastern Virginia is helping them do just that—and is being expanded across the state because of its success.

Community leaders led by five local Area Agencies on Aging (AAAs) in eastern Virginia established the Eastern Virginia Care Transitions Partnership (EVCTP) focused on assessing patients’ needs in their homes and keeping them out of the hospital as a result. Part of the program is the Care Transitions Intervention Program (CTIP), which works to provide patients and their caregivers with the skills, confidence and tools they need to take a more active role in their care. CTIP employs coaches who are professionally trained and certified to activate patients and build confidence so they can achieve the goals they have set for themselves. In-home environmental assessments identify needs beyond health and discharge plan, taking into account well-being and quality of life.

Results from EVCTP are impressive. From 2013-2015, the EVCTP conducted 25,655 total home visits for Medicare patients discharged from the hospital. Those home visits translated into fewer patient readmissions. While the 2016 average target group readmission rate was 14.4 percent, the EVCTP enrollee readmission rate was 9.1 percent—well below the 2010 readmission baseline of 23.4 percent.

Based on this success, the EVTCP program has expanded. The Commonwealth is working with three Virginia Medicare-Medicaid plans—Humana, Virginia Premier Health, and Anthem HealthKeepers—to provide care transitions and complex care coordination to members in 22 hospitals. With additional funding, the EVTCP evaluated its impact on Medicaid patients: the average readmission rate of 25 percent dropped to 13 percent.

What leads to such impressive results? The program acknowledges that older adults and people with disabilities have many different needs: transportation, chronic disease self-management, options counseling, medication management, meals on wheels, in-home care services and home repair. Moreover, coaches meet with patients in their homes to discuss any difficulties in meeting their health goals. Coaches also help identify community resources that may be available. Above all, patients say they gain confidence in how to manage their health conditions.

Recently, the greater health care community has recognized the importance AAAs can play in reducing health care costs and improving quality. The new Aging and Disability Business Institute, housed at the National Association of Area Agencies on Aging, has been established to provide training and technical assistance to enhance the business capacity of AAAs and other community-based organizations.

Similar programs are being tested across the country. In many states, health plans and health systems are partnering with local AAAs. AAAs play a critical role in the planning, development, coordination, and delivery of home and community-based services in nearly every community in the country. They have long counseled seniors and their caregivers about community resources available to help keep them independent and healthy.

Check out a full-length Success Story on Virginia’s AAA innovations in health care here.


-Nora Super is Chief, Programs & Services at National Association of Area Agencies on Aging (n4a).