Clinch Valley Medical Center - Appalachian Community Transitions (ACTion)

What is it?

Appalachian Community Transitions (ACTion) is a community-based care-transitions collaborative that serves rural southwest Virginia in partnership with the Appalachian Agency for Senior Citizens. Using a patient empowerment model, trained professionals coach patients and caregivers on how to manage medications effectively, recognize and respond to red flags that indicate a worsening condition, ensure timely follow-up with physicians, assess the home for fall prevention, and maintain a personal health record. Patients are visited in the hospital before discharge and at home, followed by three weekly visits.

Who is it for?

Any hospitalized elderly or disabled person on Medicare who is about to be discharged

Why do they do it?

The program’s goal is to improve the health of the community by easing transitions of inpatients to other care settings, enhancing quality of care and reducing readmissions for high-risk Medicare beneficiaries.

Impact

Since the program began in April 2013, 91 percent of patients have avoided a 30-day hospital readmission by staying healthier at home.

Contact: Tracie Rinehardt
Public Relations/Marketing
Telephone: 276-596-6619
Email: tracie.rinehardt@lpnt.net