The Centers for Medicare and Medicaid Services (CMS) has announced that the Kentucky Appalachian Transition Services (KATS) was selected to participate in the Community-based Care Transitions Program (CCTP). KATS will implement a transitional care program to improve medical treatment for people with Medicare. The program goal is to reduce readmissions by 20 percent among the partner hospitals over two years while improving the quality of transitional care and services to Medicare beneficiaries.

Thirty-day hospital readmissions are a national problem and facilities in mountainous, rural communities of Southeastern Kentucky and Southern West Virginia have some of the highest readmission rates in the United States. KATS will work with four hospitals in the Appalachian Regional Healthcare (ARH) network that admit more than 25,000 Medicare beneficiaries annually. Partner hospitals are located in Hazard, Harlan, Whitesburg, and South Williamson.

Collaborating partners in the KATS Transition Coalition are the Kentucky River Area Agency on Aging, Cumberland Valley Area Agency on Aging, the Kentucky Medicare Quality Improvement Organization and more than 40 other community resource providers and key stakeholders.

The most common illnesses leading to hospital admission and readmission for this population are COPD, heart disease, kidney disease and pneumonia. KATS nurses will work with the hospitals and other community partners to improve coordination of services by providing comprehensive assessments, individualized plans of care, medication assistance, education about home-safety and other follow up to promote improved health and better use of health care dollars.

The Community-based Care Transitions Program mandated by Section 3026 of the Affordable Care Act is an ongoing initiative of the Partnerships for Patients. With this CMS funding, there is an opportunity to help nearly 3,000 patients a year.