Alexi Vahlkamp of AgeOptions, who is ITCC’s close partner in the Community-based Care Transitions Program, presented last week at the Illinois Department on Aging’s 32nd annual Governor’s Conference on Aging and Disability. Part of the “Community-Based Care Transitions Program: Collaborative Models in Metropolitan Chicago”, Vahlkamp represented the AgeOptions Bridge Transitional Care Partnership. As part of the Bridge Transitional Care Partnership, 3 ITCC sites (Aging Care Connections, Solutions for Care, and Rush Health & Aging) and 3 other Aging Network Care Coordination Units (Kenneth Young Center, PLOWS Council on Aging, North Shore Senior Center) each implement the Bridge Model in partnership with a local hospital. AgeOptions, the suburban Cook County Area Agency on Aging, is the lead applicant and leads the project.
Social workers can assess and intervene around social issues, and can coordinate providers around medical issues.
As part of the CCTP application, teams must explain why they are proposing to implement a specific transitional care model in their communities. In her presentation, Vahlkamp explained that, after looking at readmission cases of partner hospitals and conducting a root cause analysis for each case, the team found that social and environmental factors and poor coordination between providers often were the direct or indirect causes of an individual readmitting. They also found that issues such as caregiver stress, poor community support, lack of patient activation and education, and social isolation were contributing factors as well. Vahlkamp described how the Bridge Model’s social work based approach has addressed these root causes at partner Chicago area hospitals since the team was awarded CCTP funding in early 2012. For more on conducting root cause analyses, visit the CMS Quality Improvement Organizations Care Transitions Toolkit.