AoA Affordable Care Act Webinars

Care Transitions What Do These Programs Look Like And How Can The Aging Network Play

a Role

AoA Affordable Care Act Webinars2

Agendabull Welcome

ndash Cindy Padilla Principal Deputy Assistant Secretary Administration on Aging (AoA)

bull Overview of Care Transitions Modelsndash Caroline Ryan Aging Services Program Specialist AoA

bull Care Transitions and the Aging Networkndash Sandy Markwood CEO National Association of Area Agencies on Aging (n4a)

bull Questions amp Answers

AoA Affordable Care Act Webinars

Care Transition Models

Caroline Ryan

Office of Program Innovation and Demonstration

Administration on Aging

AoA Affordable Care Act Webinars4

Common Care Transition Themes

bull Interdisciplinary CommunicationCollaboration

bull Transitional Care Staff

bull Patient Activation

bull Enhanced Follow‐up

AoA Affordable Care Act Webinars5

Evidence‐based Models

bull Care Transitions Interventionbull Transitional Care Modelbull Bridge Programbull BOOST (Better Outcomes for Older Adults through Safe Transitions)

bull GRACE (Geriatric Resources for Assessment and Care of Elders)

bull Guided Carereg

AoA Affordable Care Act Webinars6

Care Transitions Intervention (CTI)

Eric A Coleman MD MPH

Division of Health Care Policy and Research at the University of Colorado Denver School of Medicine

httpwwwcaretransitionsorg

AoA Affordable Care Act Webinars2

Agendabull Welcome

ndash Cindy Padilla Principal Deputy Assistant Secretary Administration on Aging (AoA)

bull Overview of Care Transitions Modelsndash Caroline Ryan Aging Services Program Specialist AoA

bull Care Transitions and the Aging Networkndash Sandy Markwood CEO National Association of Area Agencies on Aging (n4a)

bull Questions amp Answers

AoA Affordable Care Act Webinars

Care Transition Models

Caroline Ryan

Office of Program Innovation and Demonstration

Administration on Aging

AoA Affordable Care Act Webinars4

Common Care Transition Themes

bull Interdisciplinary CommunicationCollaboration

bull Transitional Care Staff

bull Patient Activation

bull Enhanced Follow‐up

AoA Affordable Care Act Webinars5

Evidence‐based Models

bull Care Transitions Interventionbull Transitional Care Modelbull Bridge Programbull BOOST (Better Outcomes for Older Adults through Safe Transitions)

bull GRACE (Geriatric Resources for Assessment and Care of Elders)

bull Guided Carereg

AoA Affordable Care Act Webinars6

Care Transitions Intervention (CTI)

Eric A Coleman MD MPH

Division of Health Care Policy and Research at the University of Colorado Denver School of Medicine

httpwwwcaretransitionsorg

AoA Affordable Care Act Webinars

Care Transition Models

Caroline Ryan

Office of Program Innovation and Demonstration

Administration on Aging

AoA Affordable Care Act Webinars4

Common Care Transition Themes

bull Interdisciplinary CommunicationCollaboration

bull Transitional Care Staff

bull Patient Activation

bull Enhanced Follow‐up

AoA Affordable Care Act Webinars5

Evidence‐based Models

bull Care Transitions Interventionbull Transitional Care Modelbull Bridge Programbull BOOST (Better Outcomes for Older Adults through Safe Transitions)

bull GRACE (Geriatric Resources for Assessment and Care of Elders)

bull Guided Carereg

AoA Affordable Care Act Webinars6

Care Transitions Intervention (CTI)

Eric A Coleman MD MPH

Division of Health Care Policy and Research at the University of Colorado Denver School of Medicine

httpwwwcaretransitionsorg

AoA Affordable Care Act Webinars4

Common Care Transition Themes

bull Interdisciplinary CommunicationCollaboration

bull Transitional Care Staff

bull Patient Activation

bull Enhanced Follow‐up

AoA Affordable Care Act Webinars5

Evidence‐based Models

bull Care Transitions Interventionbull Transitional Care Modelbull Bridge Programbull BOOST (Better Outcomes for Older Adults through Safe Transitions)

bull GRACE (Geriatric Resources for Assessment and Care of Elders)

bull Guided Carereg

AoA Affordable Care Act Webinars6

Care Transitions Intervention (CTI)

Eric A Coleman MD MPH

Division of Health Care Policy and Research at the University of Colorado Denver School of Medicine

httpwwwcaretransitionsorg

AoA Affordable Care Act Webinars5

Evidence‐based Models

bull Care Transitions Interventionbull Transitional Care Modelbull Bridge Programbull BOOST (Better Outcomes for Older Adults through Safe Transitions)

bull GRACE (Geriatric Resources for Assessment and Care of Elders)

bull Guided Carereg

AoA Affordable Care Act Webinars6

Care Transitions Intervention (CTI)

Eric A Coleman MD MPH

Division of Health Care Policy and Research at the University of Colorado Denver School of Medicine

httpwwwcaretransitionsorg

AoA Affordable Care Act Webinars6

Care Transitions Intervention (CTI)

Eric A Coleman MD MPH

Division of Health Care Policy and Research at the University of Colorado Denver School of Medicine

httpwwwcaretransitionsorg

AoA Affordable Care Act Webinars7

Care Transitions Intervention The Four Pillarstrade

bull Medication Management

bull Patient‐centered Record

bull Primary Care PhysicianSpecialist Follow‐up

bull Knowledge of Red Flags

AoA Affordable Care Act Webinars8

Care Transitions InterventionFramework

Staff Transition Coachtrade

Training 1 day training

Length of Intervention Four Weeks

AoA Affordable Care Act Webinars9

Care Transitions InterventionFramework (continued)

bull Pre‐dischargebullHospital Visit

bull Post‐dischargebullHome Visit

bullThree Phone Calls

AoA Affordable Care Act Webinars10

The Transitional Care Model (TCM)

Mary D Naylor PhD RN FAAN

New Courtland Center for Transitions and Health University of Pennsylvania School of Nursing

httpwwwtransitionalcareinfo

AoA Affordable Care Act Webinars8

Care Transitions InterventionFramework

Staff Transition Coachtrade

Training 1 day training

Length of Intervention Four Weeks

AoA Affordable Care Act Webinars9

Care Transitions InterventionFramework (continued)

bull Pre‐dischargebullHospital Visit

bull Post‐dischargebullHome Visit

bullThree Phone Calls

AoA Affordable Care Act Webinars10

The Transitional Care Model (TCM)

Mary D Naylor PhD RN FAAN

New Courtland Center for Transitions and Health University of Pennsylvania School of Nursing

httpwwwtransitionalcareinfo

AoA Affordable Care Act Webinars9

Care Transitions InterventionFramework (continued)

bull Pre‐dischargebullHospital Visit

bull Post‐dischargebullHome Visit

bullThree Phone Calls

AoA Affordable Care Act Webinars10

The Transitional Care Model (TCM)

Mary D Naylor PhD RN FAAN

New Courtland Center for Transitions and Health University of Pennsylvania School of Nursing

httpwwwtransitionalcareinfo

AoA Affordable Care Act Webinars10

The Transitional Care Model (TCM)

Mary D Naylor PhD RN FAAN

New Courtland Center for Transitions and Health University of Pennsylvania School of Nursing

httpwwwtransitionalcareinfo

AoA Affordable Care Act Webinars11

TCM Components

bull Patient and Caregiver Understanding

bull Facilitate Patient Self‐management

bull Medication Reconciliation and Management

bull Transitional Care

AoA Affordable Care Act Webinars12

TCM Framework

Staff Transitional Care Nurse

Training Web‐based training modules

Length of Intervention 1‐3 months

AoA Affordable Care Act Webinars13

TCM Framework (continued)

bull Pre‐dischargebull Daily Hospital Visits

bull Post‐dischargebull Home Visits

bull Physician Visit

bull Telephone Support

AoA Affordable Care Act Webinars14

The Bridge Program

Illinois Transitional Care Consortium

httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium

AoA Affordable Care Act Webinars12

TCM Framework

Staff Transitional Care Nurse

Training Web‐based training modules

Length of Intervention 1‐3 months

AoA Affordable Care Act Webinars13

TCM Framework (continued)

bull Pre‐dischargebull Daily Hospital Visits

bull Post‐dischargebull Home Visits

bull Physician Visit

bull Telephone Support

AoA Affordable Care Act Webinars14

The Bridge Program

Illinois Transitional Care Consortium

httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium

AoA Affordable Care Act Webinars13

TCM Framework (continued)

bull Pre‐dischargebull Daily Hospital Visits

bull Post‐dischargebull Home Visits

bull Physician Visit

bull Telephone Support

AoA Affordable Care Act Webinars14

The Bridge Program

Illinois Transitional Care Consortium

httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium

AoA Affordable Care Act Webinars14

The Bridge Program

Illinois Transitional Care Consortium

httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium

AoA Affordable Care Act Webinars15

Bridge Program Framework

Staff Bridge Care Coordinator

Training Bridge Training Module

Length of Intervention 30 days

AoA Affordable Care Act Webinars16

Bridge Program Framework (continued)

bull Pre‐dischargebull Aging Resource Center

bull Hospital Visit

bull Post‐dischargebull Phone Calls

bull Home Visit

AoA Affordable Care Act Webinars17

Better Outcomes for Older Adults through Safe Transitions (Project BOOST)

Society of Hospital Medicine

httpwwwhospitalmedicineorgResourceRoomRedesignRR_CareTransitionsCT_Homecfm

AoA Affordable Care Act Webinars16

Bridge Program Framework (continued)

bull Pre‐dischargebull Aging Resource Center

bull Hospital Visit

bull Post‐dischargebull Phone Calls

bull Home Visit

AoA Affordable Care Act Webinars17

Better Outcomes for Older Adults through Safe Transitions (Project BOOST)

Society of Hospital Medicine

httpwwwhospitalmedicineorgResourceRoomRedesignRR_CareTransitionsCT_Homecfm

AoA Affordable Care Act Webinars17

Better Outcomes for Older Adults through Safe Transitions (Project BOOST)

Society of Hospital Medicine

httpwwwhospitalmedicineorgResourceRoomRedesignRR_CareTransitionsCT_Homecfm

AoA Affordable Care Act Webinars18

Project BOOST Framework

bull Comprehensive Intervention

bull Comprehensive Implementation Guide

bull Longitudinal Technical Assistance

bull Project BOOST Collaboration

bull Project BOOST Data Center

AoA Affordable Care Act Webinars19

Project BOOST Intervention Tools

bull Standardized Discharge Processesndash The TARGET

bull PatientCaregiver Preparednessndash Patient PASS A Transition Record

ndash Teach‐back

bull Medication Safety

bull Follow‐up Care

AoA Affordable Care Act Webinars20

Geriatric Resources for Assessment and Care of Elders (GRACE)

Dr Steven R Counsell MD

Indiana University Center for Aging Research Indianapolis Indiana

httpmedicineiupuieduIUCARresearchgraceasp

AoA Affordable Care Act Webinars19

Project BOOST Intervention Tools

bull Standardized Discharge Processesndash The TARGET

bull PatientCaregiver Preparednessndash Patient PASS A Transition Record

ndash Teach‐back

bull Medication Safety

bull Follow‐up Care

AoA Affordable Care Act Webinars20

Geriatric Resources for Assessment and Care of Elders (GRACE)

Dr Steven R Counsell MD

Indiana University Center for Aging Research Indianapolis Indiana

httpmedicineiupuieduIUCARresearchgraceasp

AoA Affordable Care Act Webinars20

Geriatric Resources for Assessment and Care of Elders (GRACE)

Dr Steven R Counsell MD

Indiana University Center for Aging Research Indianapolis Indiana

httpmedicineiupuieduIUCARresearchgraceasp

AoA Affordable Care Act Webinars21

GRACE Framework

Staff GRACE Support Team bull Nurse Practitioner and Social Worker

Training 12 session training program

Length of Intervention Long Term

AoA Affordable Care Act Webinars22

GRACE Framework (continued)

bull Home Visit

bull Meeting with GRACE Interdisciplinary Team

bull Meeting with Primary Care Physician

bull Implement Individualized Care Plan

bull Additional Home Visits and Phone Calls

bull Support Transitions from Hospital to Home

AoA Affordable Care Act Webinars23

Guided Carereg

Dr Chad Boult MD MPH MBA

The Johns Hopkins University

httpwwwguidedcareorg

AoA Affordable Care Act Webinars22

GRACE Framework (continued)

bull Home Visit

bull Meeting with GRACE Interdisciplinary Team

bull Meeting with Primary Care Physician

bull Implement Individualized Care Plan

bull Additional Home Visits and Phone Calls

bull Support Transitions from Hospital to Home

AoA Affordable Care Act Webinars23

Guided Carereg

Dr Chad Boult MD MPH MBA

The Johns Hopkins University

httpwwwguidedcareorg

AoA Affordable Care Act Webinars23

Guided Carereg

Dr Chad Boult MD MPH MBA

The Johns Hopkins University

httpwwwguidedcareorg

AoA Affordable Care Act Webinars24

Guided Carereg Framework

Staff Guided Care Nurse

Training 6 week 40 hour web‐based course

Length of Intervention Long Term

AoA Affordable Care Act Webinars25

Guided Carereg Framework (continued)

bull Home Visit

bull Evidence‐based Care Plan

bull Promoting Patient Self‐Management

bull Monthly Monitoring of Patient Conditions

bull Coordinating the Efforts of all Health Care Providers

bull Smoothing Care Transitions

bull Educating and Supporting Caregivers

bull Facilitate Access to Community Resources

AoA Affordable Care Act Webinars26

AoArsquos Evidence‐based Care Transitions Grantees (16 states)

bull Massachusetts

bull New Hampshire

bull New York

bull Pennsylvania

bull Rhode Island

bull Tennessee

bull Texas

bull Washington

bull California

bull Colorado

bull Connecticut

bull Florida

bull Illinois

bull Indiana

bull Maine

bull Maryland

AoA Affordable Care Act Webinars27

AoA Evidence Based Care Transition Grantee Activity Quick Snapshot of 2010 EBCT Grants (16 States)

Hiring StaffOn Average1-3 Months

Begin Implementation 100 within 7 months or less

Estimated number of patients to be served In general range from 200 to 800 per year

Target Population 1416 Targeting Measures in Place

CTI 1216 States

BRIDGE Illinois

TCM Pennsylvania

Guided Care Maryland

GRACE Indiana

BOOST New Hampshire (also doing CTI)

AoA Affordable Care Act Webinars

Care Transitions and the Aging Network

Sandy Markwood

n4a

AoA Affordable Care Act Webinars29

Why the Aging Network Is So Critical to Care Transitions

bull UniqueTrusted Position in the Community for 40 Years

bull Intellectual Propertybull Knowledge of Older Adults and Caregiversbull Contracting Power Brokerbull Service Provision Skillsbull Quality Assurance and Outcomes

AoA Affordable Care Act Webinars30

Why Care Transitions Is So Critical to the Aging Network

bull Core Mission of Maximizing Independence for At Risk Population

bull Need to Engage in Changing LTC Landscape

bull New Revenue Stream

bull Existing Clients are High Risk for Readmission

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars25

Guided Carereg Framework (continued)

bull Home Visit

bull Evidence‐based Care Plan

bull Promoting Patient Self‐Management

bull Monthly Monitoring of Patient Conditions

bull Coordinating the Efforts of all Health Care Providers

bull Smoothing Care Transitions

bull Educating and Supporting Caregivers

bull Facilitate Access to Community Resources

AoA Affordable Care Act Webinars26

AoArsquos Evidence‐based Care Transitions Grantees (16 states)

bull Massachusetts

bull New Hampshire

bull New York

bull Pennsylvania

bull Rhode Island

bull Tennessee

bull Texas

bull Washington

bull California

bull Colorado

bull Connecticut

bull Florida

bull Illinois

bull Indiana

bull Maine

bull Maryland

AoA Affordable Care Act Webinars27

AoA Evidence Based Care Transition Grantee Activity Quick Snapshot of 2010 EBCT Grants (16 States)

Hiring StaffOn Average1-3 Months

Begin Implementation 100 within 7 months or less

Estimated number of patients to be served In general range from 200 to 800 per year

Target Population 1416 Targeting Measures in Place

CTI 1216 States

BRIDGE Illinois

TCM Pennsylvania

Guided Care Maryland

GRACE Indiana

BOOST New Hampshire (also doing CTI)

AoA Affordable Care Act Webinars

Care Transitions and the Aging Network

Sandy Markwood

n4a

AoA Affordable Care Act Webinars29

Why the Aging Network Is So Critical to Care Transitions

bull UniqueTrusted Position in the Community for 40 Years

bull Intellectual Propertybull Knowledge of Older Adults and Caregiversbull Contracting Power Brokerbull Service Provision Skillsbull Quality Assurance and Outcomes

AoA Affordable Care Act Webinars30

Why Care Transitions Is So Critical to the Aging Network

bull Core Mission of Maximizing Independence for At Risk Population

bull Need to Engage in Changing LTC Landscape

bull New Revenue Stream

bull Existing Clients are High Risk for Readmission

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars26

AoArsquos Evidence‐based Care Transitions Grantees (16 states)

bull Massachusetts

bull New Hampshire

bull New York

bull Pennsylvania

bull Rhode Island

bull Tennessee

bull Texas

bull Washington

bull California

bull Colorado

bull Connecticut

bull Florida

bull Illinois

bull Indiana

bull Maine

bull Maryland

AoA Affordable Care Act Webinars27

AoA Evidence Based Care Transition Grantee Activity Quick Snapshot of 2010 EBCT Grants (16 States)

Hiring StaffOn Average1-3 Months

Begin Implementation 100 within 7 months or less

Estimated number of patients to be served In general range from 200 to 800 per year

Target Population 1416 Targeting Measures in Place

CTI 1216 States

BRIDGE Illinois

TCM Pennsylvania

Guided Care Maryland

GRACE Indiana

BOOST New Hampshire (also doing CTI)

AoA Affordable Care Act Webinars

Care Transitions and the Aging Network

Sandy Markwood

n4a

AoA Affordable Care Act Webinars29

Why the Aging Network Is So Critical to Care Transitions

bull UniqueTrusted Position in the Community for 40 Years

bull Intellectual Propertybull Knowledge of Older Adults and Caregiversbull Contracting Power Brokerbull Service Provision Skillsbull Quality Assurance and Outcomes

AoA Affordable Care Act Webinars30

Why Care Transitions Is So Critical to the Aging Network

bull Core Mission of Maximizing Independence for At Risk Population

bull Need to Engage in Changing LTC Landscape

bull New Revenue Stream

bull Existing Clients are High Risk for Readmission

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars27

AoA Evidence Based Care Transition Grantee Activity Quick Snapshot of 2010 EBCT Grants (16 States)

Hiring StaffOn Average1-3 Months

Begin Implementation 100 within 7 months or less

Estimated number of patients to be served In general range from 200 to 800 per year

Target Population 1416 Targeting Measures in Place

CTI 1216 States

BRIDGE Illinois

TCM Pennsylvania

Guided Care Maryland

GRACE Indiana

BOOST New Hampshire (also doing CTI)

AoA Affordable Care Act Webinars

Care Transitions and the Aging Network

Sandy Markwood

n4a

AoA Affordable Care Act Webinars29

Why the Aging Network Is So Critical to Care Transitions

bull UniqueTrusted Position in the Community for 40 Years

bull Intellectual Propertybull Knowledge of Older Adults and Caregiversbull Contracting Power Brokerbull Service Provision Skillsbull Quality Assurance and Outcomes

AoA Affordable Care Act Webinars30

Why Care Transitions Is So Critical to the Aging Network

bull Core Mission of Maximizing Independence for At Risk Population

bull Need to Engage in Changing LTC Landscape

bull New Revenue Stream

bull Existing Clients are High Risk for Readmission

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars

Care Transitions and the Aging Network

Sandy Markwood

n4a

AoA Affordable Care Act Webinars29

Why the Aging Network Is So Critical to Care Transitions

bull UniqueTrusted Position in the Community for 40 Years

bull Intellectual Propertybull Knowledge of Older Adults and Caregiversbull Contracting Power Brokerbull Service Provision Skillsbull Quality Assurance and Outcomes

AoA Affordable Care Act Webinars30

Why Care Transitions Is So Critical to the Aging Network

bull Core Mission of Maximizing Independence for At Risk Population

bull Need to Engage in Changing LTC Landscape

bull New Revenue Stream

bull Existing Clients are High Risk for Readmission

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars29

Why the Aging Network Is So Critical to Care Transitions

bull UniqueTrusted Position in the Community for 40 Years

bull Intellectual Propertybull Knowledge of Older Adults and Caregiversbull Contracting Power Brokerbull Service Provision Skillsbull Quality Assurance and Outcomes

AoA Affordable Care Act Webinars30

Why Care Transitions Is So Critical to the Aging Network

bull Core Mission of Maximizing Independence for At Risk Population

bull Need to Engage in Changing LTC Landscape

bull New Revenue Stream

bull Existing Clients are High Risk for Readmission

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars30

Why Care Transitions Is So Critical to the Aging Network

bull Core Mission of Maximizing Independence for At Risk Population

bull Need to Engage in Changing LTC Landscape

bull New Revenue Stream

bull Existing Clients are High Risk for Readmission

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars31

Care Transition Themes How Do They Relate to The Older Americans Act (OAA) and Aging Network Services

Interdisciplinary Teams amp Service Coordination

Enhanced Follow‐Up PatientClient Activation

bull Coordination of services (medical human services)

bull Workforce development and training

bull Planning

bull Partnerships

bull Coordination of benefits

bull Case Management Care Coordination

bull In‐home services

bull Home‐delivered meals

bull Transportation

bull Monitoringassistive devicesPERS

bull Medication mgmt

bull Disease prevention amp health promotion

bull Patientclient assessments

bull Self‐directed carecoaching

bull Healthnutrition education

bull Insurance counseling

bull Family caregiver support counseling training

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars32

OAA Services within Care Transition ThemesInterdisciplinary Teams and Service Coordination

bull Coordination services (seamlessly bridging medical amp human services)

bull Workforce development amp training (standards)bull Develop Area and Strategic Plans including business development

bull Create new partnerships especially with health systems

bull Coordinate access to benefits

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars33

OAA Services within Care Transition ThemesEnhanced Follow‐Up

bull Case managementCare coordinationndash Develop implement monitor

individual service plans

bull In‐home servicesndash Home healthndash Personal Carendash Homemakerndash Visitingtelephone reassurancendash Chore

bull Nutritionhome‐delivered meals

bull Transportationbull Monitoringassistive

devicesPERSbull Medication managementbull Disease preventionhealth

promotionndash Health risk assessmentndash CDSMPndash Evidence‐based programsndash Home injury screenings

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars34

OAA Services within Care Transition ThemesPatientClient Activation

bull Comprehensive patient client assessments including homecaregiver assessments

bull Self‐directed carecoachingbull Healthnutrition educationbull Benefitsinsurance counselingbull Family caregiver support counseling training

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars35

Care Transitions Opportunities and Considerations for the Aging Network

bull Capacity To expand your agencyrsquos business model develop and sustain new partnerships establish fee for service billing systems

bull Human Resources To expand and enhance existing operations (quick turnaroundpossible 247 services)

bull PartnershipProvider Relations To respond to broad scope of care transitions service needs

bull Culture Change To expand your agencyrsquos position‐ a new way of doing the business your agencystaffproviders have been doing

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars36

Resources Models

bull httpwwwcaretransitionsorg (Care Transitions Intervention)

bull httpwwwtransitionalcareinfo (The Transitional Care Model)

bull httphmprgorgprograms‐projectsillinois‐transitional‐care‐consortium (The Bridge Program)

AoA Affordable Care Act Webinars37

Resources Models (continued)

bull httpwwwhospitalmedicineorgResourceRoomRedesignRR_CareTransitionsCT_Homecfm(BOOST)

bull httpmedicineiupuieduIUCARresearchgraceasp (GRACE)

bull httpwwwguidedcareorg (Guided Carereg)

AoA Affordable Care Act Webinars38

Other Resources Care Transitions

bull httpwwwcmsgovDemoProjectsEvalRptsMDitemdetailaspitemID=CMS1239313 (Community‐based Care Transitions Program)

bull httpwwwadrc‐taeorgtiki‐indexphppage=CareTransitions (AoArsquos Aging and Disability Resource Centers and care transitions)

bull httpwwwcfmcorgcaretransitionsDefaulthtm(Care Transitions Quality Improvement Organization Support Center)

AoA Affordable Care Act Webinars39

Resources Affordable Care Act

bull httpwwwaoagovAging_StatisticsHealth_care_reformaspx (AoArsquos Health Reform web page)

bull httpwwwhealthcaregov (Department of Health and Human Servicesrsquo health care reform web site)

bull httpwwwthomasgovcgi‐binbdqueryDd1111temp~bdsYKv|homeLegislativeDataphpn=BSSc=111| (Affordable Care Act text and related information)

AoA Affordable Care Act Webinars40

Next Training

bull Care Transitions Making the Programmatic CasendashWednesday February 9 200‐330 pm EST

ndashWatch your email for registration information

AoA Affordable Care Act Webinars41

QuestionsCommentsSuggestions for Future Webinar Topics

Send them to

AffordableCareActaoahhsgov

AoA Affordable Care Act Webinars41

QuestionsCommentsSuggestions for Future Webinar Topics

Send them to

AffordableCareActaoahhsgov