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Office for the Aging Receives State Grant to Fund "Transitions" Program

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Office for the Aging Receives State Grant to Fund "Transitions" Program

Thursday, January 15, 2015

The Tompkins County Office for the Aging has received a $223,365 grant from the New York State Balancing Incentive Program Innovation Fund to fund a Transitions Program to serve high risk Medicaid beneficiaries.

Grant funds will be used to offer services to Medicaid beneficiaries upon discharge from local hospitals or skilled nursing facilities to assist with the transition from facility to home.  The overall goal is to improve patient health outcomes, reduce avoidable hospital admissions, and enable individuals to manage their health conditions successfully at home.

The TRANSITIONS grant will be administered by the Office for the Aging, with program implementation by Visiting Nurse Services of Ithaca and Tompkins County and CAP Connect.  Other participating clinical partners include Cayuga Medical Center, Schuyler Hospital, Beechtree Care Center, Cayuga Ridge and Seneca View, as well as CAP primary and specialty physician practices.

Studies have found that patients with chronic diseases have difficulty managing their care and medications once they are discharged from the hospital or skilled nursing facility. Through the Transitions Program, trained nurses will work with eligible patients after discharge, using strategies proven to empower high-risk patients to better mange their own care and to reduce unnecessary re-hospitalizations.

Upon discharge from the hospital or skilled nursing facility, Medicaid beneficiaries participating in the TRANSITIONS shall receive one or more home visits by a registered nurse, which includes review of discharge instructions, medication reconciliation, disease/diagnosis-specific teaching, follow up with primary care physicians, and referral to additional community supports.