Eastern Virginia Care Transitions Partnership program helps transitions to home reduced re-hospitalizations and will now expand across the region.

Newport News, VA – Riverside Health System and Bay Aging earned The Patient Care 2013 Virginia Healthcare Innovators Award for their work in coaching patients through their transition from a hospital stay to home. The program – a pilot that will now be available to thousands of additional patients across Eastern Virginia – reduced the number of Medicare patients with chronic illnesses who were readmitted to the hospital after discharge.

“Among the many reasons we are fortunate to live in the Commonwealth are the creativity and ingenuity of the many organizations here that facilitate, provide and finance healthcare for our citizens,” said Joe McMenamin, Co-Chair of the Virginia Healthcare Innovators Council, who presented the award earlier this month.

The purpose of the Virginia Healthcare Innovators Awards is to recognize Virginia organizations that have developed innovative ways to improve healthcare quality and efficiency. Organizations nominated were evaluated on uniqueness of a product or service, demonstrated success to patients, and broad potential impact.

The Riverside and Bay Aging pilot program worked collaboratively with the Williamsburg-based Riverside Center for Excellence in Aging and Lifelong Health, which, among other support, helped implement the pilot within Riverside Health System’s hospitals.

The pilot program was designed in 2011 and executed in 2012, based on the Coleman Care Transitions Intervention (CTI) process. The nationally acclaimed process encourages patients to take a more active role in their healthcare and gives patients specific tools and skills that are reinforced by a transition “coach” who follows patients across settings for the first four weeks after leaving a hospital.

The Bay Aging and Riverside pilot program brought healthcare coaches certified in the Care Transitions Intervention from the Area Agencies on Aging into the Riverside Walter Reed Hospital in Gloucester, the Riverside Tappahannock Hospital and Rappahannock General Hospital to work directly with patients and families preparing to transition home. The coach then followed up with patients in their homes, teaching them how to develop personal health records, medication management skills, set goals, prepare for follow up doctor visits and identify concerns that their health condition may be worsening.

Of the 140 Medicare patients who completed the Bay Aging and Riverside pilot program, 98 percent avoided getting readmitted to the hospital within a month of having returned home, amounting to an estimated savings of approximately $1 million and potentially reducing adverse effects of hospital care, especially for the frail elderly.

Nationally, an average of 20 percent of Medicare patients are readmitted to hospitals within 30 days of discharge, said Kathy Vesley-Massey, President and CEO of Bay Aging.

Due to the success of the Bay Aging and Riverside pilot study, the Center for Medicare and Medicaid Services awarded funding to bring the program to 11,000 patients this year through the Eastern Virginia Care Transitions Partnership (EVCTP). EVCTP is comprised of five Area Agencies on Aging (AAAs) and five health systems (11 hospitals), which cover 20 percent of Virginia. The five AAAs include Bay Aging, Peninsula Agency on Aging, Inc., Eastern Shore AAA, Senior Services of Southeastern Virginia and Rappahannock AAA. 

In addition to the pilot hospitals, the program now includes patients at Riverside Shore Memorial Hospital on Virginia’s Eastern Shore, Riverside Regional Medical Center in Newport News, Riverside Doctors’ Hospital Williamsburg and Mary Washington and Stafford Hospitals in Fredericksburg. It is also being launched at Sentara CarePlex in Newport News and Sentara Williamsburg Regional Medical Center.  Plans are underway to expand to Bon Secours Mary Immaculate and further into South Hampton Roads.

“Offering innovative and person centered levels of care for older adults is a principal of Riverside’s work across the state,” said F. Michael Martin, who serves as Riverside’s Senior Vice President for the Lifelong Health and Aging Related Services division. “More than 10,000 people turn 65 per day. By staying innovative and constantly improving the ways people access healthcare we are able to help older adults age in a place and in a manner of their choosing.”

Riverside recently opened the first freestanding household model nursing home – Heron Cove at Sanders in Gloucester, Va. – that offers a transformative and de-institutionalized approach to care. Riverside also provides home health and technologies that enable older adults to age in place, and operates the fastest-growing Program of All-Inclusive Care for the Elderly (PACE) in the country.

The “Caring For You, Caring For Me” program in Williamsburg, which provides support to Virginians caring for older adults through Riverside’s Center for Excellence in Aging and Lifelong Health (CEALH), placed first in the Commonwealth Council on Aging’s 2013 Best Practices Award Program.

Kathy Vesley-Massey of Bay Aging and Dr. Kyle Allen of Riverside are available for interviews upon request. To schedule an interview or for more information, please contact Peter Glagola, Director Public Relations, Riverside, at peter.glagola@rivhs.com or 757.719.2103.

Published: June 10, 2013