Care Transitions

Community Based Care Transitions Program (CCTP)

The Alliance for Aging, Inc., the designated Area Agency for Aging for Miami-Dade and Monroe counties, Florida (AAA), has partnered with Baptist Hospital of Miami, Doctors Hospital, Jackson Health System, Larkin Community Hospital, Mount Sinai Medical Center, South Miami Hospital, Walgreens Pharmacy, and University of Miami Hospital to form the Greater Miami Coalition to Prevent Unnecessary Re-hospitalizations (GMCPUR). Additional partnership members include five community based organizations with extensive case management and social service experience:  First Quality Home Care, Jewish Community Services, Miami Jewish Health Systems, Specialized Nursing Services, and United Home Care. The partnership is committed to providing care transition services (one-on-one Coaching in the hospital as well as the home and/or Skilled Nursing Facility) to eligible Medicare beneficiaries discharged from the hospitals in the GMCPUR Community.  Another partner, Independent Living Systems (ILS), will provide support to the coalition coaches by coordinating telephonic follow-up for the agencies.

Through this initiative the Alliance will provide hospital to home transition services each year to 8,112 Medicare fee for service beneficiaries, who are at high risk of re-hospitalization within 30 days of discharge. This five-year initiative is expected to generate over $7 million in savings each year from avoided unnecessary re-hospitalizations and is a valuable Medicare benefit.

Two additional components support the GMCPUR Coaching Intervention consisting of at home meals (10 meals) for patients who have short-term nutrition needs upon discharge and post discharge medication transition intervention which will be provided by Walgreens Pharmacy.  This intervention also provides a service to patients by delivering discharge medications to the patient’s bedside prior to leaving the facility. 

The coaching intervention will target Medicare fee-for-service beneficiaries (including dual-eligible beneficiaries 21 years of age or older) and patients must present with primary diagnoses of AMI, HF, PNE, or any of the following conditions associated with the greatest percentage of readmissions for the community:

  • Septicemia/shock
  • Urinary tract infection
  • Vascular or circulatory disease
  • Chronic obstructive pulmonary disease
  • Peptic ulcer, hemorrhage, other specified gastrointestinal disorders
  • Renal failure
  • Diabetes or diabetes mellitus complications, or
  • Major complications of medical care and trauma

If you have any questions or would like additional information regarding this new Medicare initiative, please feel free to contact Tamara Ovadia-Milian, MSW, Community-Based Care Transitions Program Administrator, at 305-671-6326 or via e-mail at ovadiat@elderaffairs.org.