Allegheny County DHS Announces Federal Funding from the Centers for Medicare and Medicaid Services to Help Reduce Hospital Readmissions

PITTSBURGH –The Allegheny County Department of Human Services (DHS) Area Agency on Aging has received funding from the Centers for Medicare and Medicaid Services (CMS) to assist in the county’s efforts on reducing hospital readmission for Medicare Fee-for-Service beneficiaries. 

The funding comes from the CMS Community-based Care Transitions Program (CCTP), and will provide transition services to residents of Allegheny County in partnership with five area Acute Care Hospitals. The participating hospitals include three West Penn Allegheny hospitals-- Allegheny General Hospital, Allegheny Valley Hospital and Forbes Regional Hospital-- as well as Ohio Valley General Hospital and Jefferson Regional Medical Center. 

“We are very enthusiastic about the ability to adopt a community approach to reducing hospital readmissions,” said DHS Director Marc Cherna. “This funding enables us to implement a program that combines expertise from our medical and social service networks and perhaps create a model that can be duplicated in other areas.” 

The CCTP will establish Care Transitions Intervention Coaches to work with acute care patients and help them to understand and monitor their own care. Interaction will begin with an in-hospital visit just before discharge, a follow-up at-home visit, and then several phone calls in the first month after release. The coach will empower the patient to manage their own medications, personal health and warning signs, and help the patient to communicate effectively with health care providers. 

“Nearly 46 percent of Allegheny County’s Medicare population is fee-for-service beneficiaries and by partnering with these five hospitals, we can target more than 2,900 people annually,” said Area Agency on Aging Administrator Mildred Morrison. “Curbing hospital readmissions among this population would provide a definite cost savings in the long run.” 

Created by the Affordable Care Act, the Allegheny County CCTP is a two-year program agreement, with the option for renewal.  More information on the CMS can be found at the  Center for Medicare & Medicaid Innovation.

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