Closing care transition gaps for these populations is the focus of "Coordinating Care Transitions for the Elderly and Dually Eligible: Fostering Self-Management and Reducing Readmissions."

Contributing Authors

Throughout this 65-page report, these respected thought leaders will share their unique approaches to care transition management that positively impact cost and engage the patient in their care decisions:

• Danielle Butin, director, northeast health services for Secure Horizons, United Healthcare;
• Diane Flanders, director of coordinated care systems at MassHealth, a unit that oversees the state’s integrated Medicare-Medicaid managed care programs, including Senior Care Options (SCO) and the Program of All-inclusive Care for the Elderly (PACE;
• Sarah Keenan, clinical liaison with Medica; and
• Gregg Lehman, PhD, president and chief executive officer of INSPIRIS at time of contribution and current president and CEO of Minneapolis-based Health Fitness Corp.

This report is based on 2006 and 2007 audio conferences on the importance of overseeing care transitions in the Medicare, Medicaid and dual-eligible populations.

Table of Contents

• Integrating Health Coaching Into a Comprehensive Health Management Effort
  • Using Health Coaching to Better Manage Transitions and Improve Empowerment
  • Implementing Health Coaching Programs
  • Results of Health Coaching in Managed Care
  • Transition Coach Program
  • Advanced Illness and Coordinated Care Program (AICC)
  • Polypharmacy Transitions
  • Options for Living Self-Management Programs
  • Results of Living Self-Management Programs
• Managing Transitions for Medicare Patients to Avoid Costly Inpatient Admissions
  • The Frail Elderly -- Growing Need, Growing Problem
  • The Changing Role of Family Caregivers
  • Ten Most Common Reasons for Hospitalizations Among the Elderly
  • How and When Breakdowns Occur
  • Acute Problem Management
  • Physician Relationship Management
  • Utilization and Cost Outcomes
  • The Dually Eligible Medicare and Medicaid Population: A Care Coordination Perspective
  • Program Eligibility Criteria
  • The Provider Payment Method
  • Defining Care Coordination and Its Functions
  • Working with Elderly Waiver Services
  • Transitions to Care and Healthcare Directives
  • Emergency Care Plans Prevent Surprises
  • Preventive Care for Seniors
  • Barriers to Compliance
• Senior Care Options (SCO): Bringing Medicare and MassHealth Together
  • Objectives of the Senior Care Options Program
  • SCO Milestones
  • Managing a Merge of Medicaid and Medicare Services
  • SCO Highlights
  • How the Payment System Works
  • Senior Care Organizations
• Q&A: Ask the Experts
  • Predicting Inpatient Acute Utilization
  • Managing Fractures on an Outpatient Basis
  • Criteria for Identifying Pre-Hospice Patients
  • Acute Problem Management
  • Geriatric Depression Scale and Mini Mental Status Exams
  • Funding & Reimbursement
  • Interventions for Self-Management Disease Programs
  • Health Coaching in Pharmacy Outreach Programs
  • Determining the Frequency of Maintenance Visits
  • Components of the Home Visit
  • Training Transition Coaches
  • Training Nurse Practitioners
  • Care Transitions for the Dually Eligible
  • Care Transition Coordinator Caseload
  • Coordination Between Aging Programs
  • Following Geriatric Standards
  • Methods of Making Patient Contact
  • Integrating Utilization and Mental Health Responsibilities
  • The Long-Term Care Consultation Form
  • Recruiting Beneficiaries When Enrollment Is Voluntary
  • Keeping Nurse Case Managers Current
  • Dissecting the Central Enrollment Record
  • Avoiding Unnecessary ER Utilization
  • Nurse Care Managers and 24/7 Coverage
  • Nurse Case Manager Employment
• Glossary
• For More Information
• About the Authors