Adapting Care Transitions Amidst Pandemic
Council on Aging of Southwestern Ohio | Cincinnati, OH
Tuesday, May 5, 2020
Section: COVID-19 Resources

The Council on Aging of Southwestern Ohio (COA), the state-designated Area Agency on Aging for Southwest Ohio, provides care management as well as home and community-based services to more than 25,000 individuals in its region. COA was able to provide care transitions with funding from the Centers for Medicare & Medicaid Services’ Community-based Care Transitions Program (CCTP). But when CCTP funding ended, COA’s care transitions program did not. COA found a way to braid together local and federal funding to support a scaled-down version of its CCTP program. Called Fast Track Home, the program has grown and is now in place in most large hospitals in Cincinnati, OH.
COA is actively responding to the COVID-19 crisis by adapting its Fast Track Home model to better support patients returning home from hospitals and skilled nursing facilities, as well as hospitals encountering a surge in demand. These adaptations include:
  • Broadening the process to encompass all COA programs;
  • Changing the referral and coaching model by establishing telephonic coaching protocols, dropping hospital its coaching presence and adding an intake queue;
  • Ramping up capacity by shifting staff resources and training, and expanding days of operation to seven days a week; and
  • Adapting provider capacity and service delivery procedures by developing provider guidance and protocols to ensure services continue to be provided safely and in alignment with guidelines from the Centers for Disease Control and Prevention; expanding the availability of home-delivered meals to seven days a week and including therapeutic meals; and adapting services that have proven to be popular with individuals leaving hospital settings such as Durable Medical Equipment, homemaking and personal care services, Emergency Medical Response Systems and transportation to primary care appointments.
To learn more about how COA is adapting services to respond to the changing needs of older adults and people with disabilities during the COVID-19 crisis, watch a recording of the Aging and Disability Business Institute’s webinar, Hospital Without Walls: New Opportunities for CBOs.