Health Care Reform a High AAA Priority

Area Agencies on Aging ("triple As," as they're sometimes called) have long contributed to health care efficiencies and effectiveness. Aging and Disability Services (ADS) is designated by the State of Washington as the Area Agency on Aging for King County. It is part of a nationwide aging services network. With more than 30 years experience providing long-term case management services and contracting with community-based organizations to provide a broad range of supports, ADS has helped tens of thousands of older adults with functional disabilities to remain independent in their own homes.

In 2009, ADS launched a chronic care management program called King County Care Partners (KCCP) that provides RN-led care coordination for high-cost Medicaid beneficiaries with behavioral health issues and multiple chronic conditions. By assessing risk factors, health literacy, and self-management skills; screening for alcohol and substance abuse, depression, and other mental health conditions, as well as chronic conditions such as diabetes and heart disease; teaming up with the client's health care provider; and coaching the client toward successful self-management of their conditions, KCCP has increased access to health care services and reduced health care costs.

Last year, ADS took another step into the health care reform arena by reaching out to south King County hospitals to discuss effective care transitions among Medicare beneficiaries—from hospital to home or nursing facility—that can reduce the number of preventable readmissions. Nationwide, nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days, and many of these admissions are preventable. This translates to unnecessary pain and suffering as well as more than $26 billion in additional hospital care costs every year. The issues are not limited to Medicare—readmission rates are also high for patients covered by Medicaid and private insurance.

In April, ADS, Highline Medical Center, Highline Medical Services Organization, Valley Medical Center, and Qualis Health (the Medicaid improvement organization for Washington and Idaho) co-sponsored a community meeting to discuss care transitions. More than 130 people attended, representing 65 organizations. The meeting report highlights the challenges: coordination, communication, and collaboration.

Care transitions collaboration continues as the sponsoring organizations develop more effective processes and tools to improve the quality of care at every step—pre-admission, at admission, during hospital stay, at discharge, at a skilled nursing facility, at home, and at a primary care clinic. Everyone has a role—patients, health care providers, case managers, and even informal caregivers like friends and neighbors.

To build upon this work over the coming year, ADS will facilitate a number of work groups and host several special events. To stay informed, e-mail to request addition to the Care Transitions listserv. For additional background information and meeting materials, visit

—Jesse Eller, Aging and Disability Services