Care at Hand

The historical progression of bundled payments from acute care to post-acute care and the growing recognition of the value of HCBS create an interesting opportunity for sustainably integrating medical services with other (LTSS). Building on past lessons from efforts to incorporate community-based LTSS into traditional medical care models, such as care transitions, may help to inform successful future strategies to enable bundles to more efficiently achieve the Triple Aim.

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an AAA in Northeastern Massachusetts) visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Review the AHRQ study that gave the program a moderate evidence rating for improving outcomes, decreasing cost of care.