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800-AGE-INFO: Additional Information for Massachusetts Elders
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Care Transitions

Our Care Transitions Programs help older and disabled adults transition from the hospital or rehab setting to home.  Our programs are designed to improve the care of newly discharged Medicare beneficiaries at high risk for readmission to the hospital.

Tri-Valley has certified Coleman Coaches™ on staff to provide care transitions coaching to eligible disabled and older adults.  The Coleman Care Transitions Intervention Program™ is an evidence-based program that has been proven to reduce preventable re-hospitalizations with its Care Transitions Intervention™ Model.

Our Transition Coaches provide a patient centered approach to teach self-management skills, and use specific tools to help ensure that transition needs are addressed in a timely and appropriate manner.  Transition Coaches serve as a knowledgeable resource for patients as they move across different health care settings.  Patients and their caregivers are coached to take a more active role during these care transitions.

Through planned Transition Coaching in the home setting, Tri-Valley facilitates positive experiences for older and disabled adults as they progress in their post-hospital recovery with positive results in reducing unnecessary hospital readmissions.

Tri-Valley has been actively collaborating with our community health care partners to reduce preventable readmissions and to improve patient outcomes.  Tri-Valley has been an active participant of the Massachusetts STAAR Initiative.

Tri-Valley’s “Returning Home with You” CTI Post-Hospitalization Program was initiated in 2011 with our State Home Care clients returning home from hospitals and skilled nursing facilities.

In the spring of 2011, Tri-Valley began collaborating with community partner, Milford Regional Medical Center, to implement the Program for Medical Center patients returning home from the hospital.  The pilot study’s findings demonstrated that a partnership to effectively reduce preventable readmissions of elderly high risk patients with chronic and multiple conditions can be successfully achieved.  The Executive Summary of the May 2012 final report is available in Adobe PDF format.

In 2012, Tri-Valley joined the Central Mass/MetroWest Transitions in Care Collaborative, a Center for Medicare and Medicaid Services (CMS) approved Community-Based Care Transitions Program (CCTP) Demonstration Site.  Tri-Valley, with our Aging Services Access Points partners, provides its Transition Coaches to serve Medicare beneficiaries for two health care systems, UMass Memorial Medical Center and Vanguard Health System.  Tri-Valley’s Transition Coaches provide Coleman CTI Coaching to University, Memorial, and Wing Hospitals for UMass Memorial Medical Center; and St. Vincent, Framingham Union, and Leonard Morse Hospitals for Vanguard Health System.  Tri-Valley continues to invite collaborative partnerships with health care providers in our Southern Worcester county service area to work with us to improve health care outcomes.