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Care Transitions


Minnesota’s Area Agencies on Aging provide critical support to individuals as they face care transitions across care settings or from one home to another.

The Area Agency and its network of service providers offer access to:

  • Home-delivered meals and grocery delivery to support adequate nutrition.
  • Medication management services and assistance with Medicare Part D or other prescription drug payment issues to help older adults meet the challenges of medication compliance.
  • Transportation services to ensure follow-up with the physician.
  • Chore help, homemaker services, and home modifications to create a home environment essential to aid recovery and maintain health.
  • Respite services and coaching for family caregivers to support them as they give hands-on care for loved-ones.
Reducing Rehospitalizations through Better Care Transitions

Rehospitalization—repetitive hospitalizations of patients with chronic disease—has tremendous impact on both an individual’s quality of life and cost. A successful approach to avoiding rehospitalization requires a community-wide response and Minnesota’s AAAs are pivotal to a successful response.

Minnesota’s Area Agencies are at the forefront of innovative approaches to care transitions. The Metropolitan Area Agency on Aging and its partners recently conducted a root cause analysis to better understand the factors that drive rehospitalization of Medicare beneficiaries within 30 days of discharge. The most prevalent causal factors identified were:

  • Insufficient, late or non-existent post discharge follow-up with physician
  • Lack of follow-through by patient at home
  • Medication management issues
  • Absent or insufficient enlistment of short or long-term services, and
  • Lack of standardization and inadequate processes at discharge

Minnesota’s Area Agencies are ready and waiting to be tapped in local and statewide efforts to address these issues and to reduce repeat hospitalizations of older adults.