Southwest Ohio Care Transitions Collaborative

New video: A Story of Patient Empowerment

Purpose

To reduce costly and avoidable hospital readmissions as well as improve health outcomes and quality of life by empowering seniors to manage their chronic health conditions.

Description

Care Transitions is a health coaching and intervention program in Greater Cincinnati for older adults who have been hospitalized for serious and usually chronic conditions, such as heart failure.  It is designed to:

• Help frail seniors who have been discharged from the hospital avoid future preventable hospital admissions
• Help patients access the most appropriate post-acute medical care and home and community-based services (and avoid the more costly nursing home placements when not necessary)

View the video below for some Care Transitions highlights:

Specific Goals and Responsibilities

This program utilizes the care transitions model of patient coaching, information technology and coordination across care settings.

The partner organizations are working collaboratively to:

• Reduce Readmissions
• Diminish Disparities in Care
• Improve the Patient Experience and
• Enhance Patient Safety

Community Partners

Partners in the Southwest Ohio Care Transitions Collaborative include:

• Council on Aging of Southwestern Ohio
• Greater Cincinnati Health Council
• Hamilton County Mental Health and Recovery Services Board
• HealthBridge
• Health Care Access Now
• The Health Collaborative
• And the following hospitals:
  • The Christ Hospital
  • Clinton Memorial Hospital
  • The Jewish Hospital – Mercy Health
  • Mercy Health – Fairfield Hospital
  • UC Health – University of Cincinnati Medical Center

Health Council Contact
For more information, please contact Sheri Vogel.