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"A common arrangement is for Area Agencies on Aging (AAAs) to operate CTI programs and receive referrals from hospitals or health plans. Some AAAs have contracts with hospitals or health plans that pay for the work of the Transitions Coach, while others receive funding through the Older Americans Act or foundation grants. In addition, some health plans, home health agencies, community-based organizations, and educational institutions employ their own Transitions Coaches to serve patients or members."

Care Transitions Intervention: Coaching Patients to Successfully Transition from Hospital to Home | Playbook Highlights the Care Transitions Intervention (CTI), an evidence-based, short-term model that helps prevent unnecessary hospital readmissions and emergency department visits and reduce unnecessary spending.

Ohio's Area Agencies on Aging have a number of services to offer health care systems and payers.

Did you know 50 percent of Area Agencies on Aging that contract with health care entities provide a variety of social services for older adults? Read more about the benefits of contracting in a new infographic from our Aging and Disability Business Institute: bit.ly/3S1eqz4.

"Three common characteristics emerged that describe the organizational culture of AAAs with a high number of health care partners:

Attention to external environments;
Openness to innovation and change; and
Risk taking to learn, improve, and grow."

Supporting Older Adults’ Social Needs Through Partnerships Between Area Agencies on Aging and Health Care Organizations | Playbook New research sheds light on the strategies Area Agencies on Aging (AAAs) use to create and maintain partnerships with health care entities.

"Area Agencies on Aging and other aging network service providers can help to achieve Triple Aim goals by adding value in managing chronic conditions; activating patients and families; reducing hospital readmissions; avoiding long-term institutionalization; and helping people continue living in the community where they overwhelmingly prefer to be. The trend toward integration presents unique opportunities for AAAs ... to contract with healthcare entities seeking to address the health-related social needs of the people whom they serve."

Doing Business: A Pathway to Coordination Why AAAs are busy contracting with community-based organizations, and how it's paying off.

The Aging and Disability Business Institute is excited to have a new journal article posted in Society of Certified Senior Advisors' CSA Journal. Read the article to learn how collaborations between health care entities and aging and disability CBOs can help meet the needs of a growing population of older adults now and in the future. http://ow.ly/RzEO50EhXwr

The Critical Role of Area Agencies on Aging in Addressing the Health-Related Social Needs of Older Adults | Playbook Explores findings from the AAA National Survey conducted by n4a and Scripps Gerontology Center at Miami University, which shed light on the wide range of needs that AAAs address in their communities, as well as the expertise their staff bring to meet those needs.

This is what we do in a variety of settings.

"Connecting older adults with social services through the healthcare delivery system may lead to decreases in hospitalizations, ED visits, and observation stays. Implementation of cross-sector partnerships that address non-clinical factors that impact the health of older adults may reduce the use of costly healthcare services."

Aligning Social and Health Care Services: The Case of Community Care Connections | Playbook Authors Elisa M. Fisher Kelley Akiya Annie Wells Yan Li Christine Peck José A.Pagán Source Preventive Medicine https://www.journals.elsevier.com/preventive-medicine Peer-Reviewed Article November 2020 Headline Community Care Connections, a program assisting older adults with complex needs in navig...

"So leveraging community partners is key to social determinants of health strategies. Working with community partners, providers have increased awareness of the community’s resources and can refer patients to helpful services."

Broad Social Determinants of Health Approaches Focus on Community Provider organizations are targeting all social determinants of health and working with community partners to address these challenges, recent work from Insights by Xtelligent Healthcare Media showed.

"The updates made in this final rule also clarify that MA plans can seek partnerships with CBOs to provide SSBCI and health-related benefits under the broader definition....These rule changes are important because they open the door even wider for MA plans to contract with aging and disability CBOs to deliver services that are part of SSBCI and health-related supplemental benefits that can improve health outcomes and quality of life for plan members."

Changes to Medicare Advantage Reinforce the Role of CBOs in Supplemental Benefits - Aging and Disability Business Institute A final rule published by the Centers for Medicare & Medicaid Services (CMS) earlier this year has implications for aging and disability community-based organizations (CBOs) seeking and engaging in contract work with Medicare Advantage (MA) plans. The new rule aligns existing regulation with a serie...

With years of expertise in delivering home and community based services addressing the social determinants of health for older adults and people with disabilities, Ohio's Area Agencies on Aging are well positioned to deliver Medicare Advantage Special Supplemental Benefits for Individuals with Chronic Illness.

Find out more about Medicare Advantage SSBCI:https://bipartisanpolicy.org/wp-content/uploads/2020/12/BPC-One-Pager-Final.pdf