Officially opening on May 4, 2010, the North Central Aging and Disability Resource Center became the third of its kind in Connecticut. Known nationally by its acronym ADRC, Aging and Disability Resource Centers are tasked with serving as highly visible and trusted places where people can turn for the full range of long term support options.
Currently funded through a grant from the US Administration on Aging, the North Central ADRC, also known as the Community Choices program helps individuals and their families identify necessary services regardless of age, financial disposition, or health status.
Core components of the Community Choices program include:
- Information giving
- Long Term Support Options Counseling
Independence Unlimited, together with regional partners North Central Area Agency on Aging and CT Community Care, Inc. are proud to provide this important program for our constituents in the Greater Hartford Area.
Community Passport to Care Program
Independence Unlimited partners with Connecticut Community Care to provide options counseling under the new ComPass 2Care Project. Options Counseling will allow exploration of service options to assist eligible participants in returning home from the hospital and remaining in the community.
Connecticut Community Care, Inc.Community Passport to Care Program (ComPass2C)
What is Community Passport to Care (ComPass2C)?
Connecticut Community Care, Inc. (CCCI) was awarded funding by the Centers for Medicare and Medicaid Community-based Care Transitions Program to implement ComPass2C, a program to improve care transitions for Medicare beneficiaries from the hospital to community and post-acute care settings. The program is meant to improve quality of care, reduce avoidable readmissions, and document measurable savings to the Medicare Program.
How does ComPass2C work?
Care transition coaches and nurses employed by CCCI are assigned to specific hospitals to engage eligible beneficiaries in the transition process. The program is free to participants (and hospitals). Coaches work with individuals to improve their understanding of how to manage their post discharge care, link them to community resources, build self-efficacy and improve health literacy. The transition coaches and nurses meet with eligible individuals in the hospital to explain the program, obtain informed consent, assess readmission risk and develop a working relationship. Risk assessment is guided by the Project Boost 8P tool; the General Assessment of Preparedness tool and the Patient Health Questionnaire -2 question depression screen. . Low risk individuals will receive in-hospital coaching and one or more follow-up phone calls. Moderate risk individuals will receive in-hospital coaching and follow-up home visits based on Dr. Eric A. Coleman's Care Transition Intervention™. High risk individuals will receive coaching, health education and monitoring using the Transitional Care Model™ developed by Mary D. Naylor, PhD, RN, FAAN. On a systems level, the program will be able to give feedback to all community partners regarding transition challenges, quality indicators and root causes of poor outcomes.
Who is eligible to participate in ComPass2C?
Medicare beneficiaries age 18 or older with any of the following diagnoses:
cardiac/vascular diagnoses (heart failure, myocardial infarction, stroke, transient ischemic attack)
respiratory diagnoses (pneumonia, chronic obstructive pulmonary disease, asthma)
Medicare/Medicaid beneficiaries with multiple chronic conditions and a history of multiple readmissions.
The program will also provide services to individuals with depressive symptoms, cognitive impairment or persons discharged to nursing homes.
Who is not eligible to participate in ComPass2C?
Individuals who are covered under Medicare Advantage Plans
Individuals enrolled in a clinical trial or hospice program
Individuals transferred to another hospital within one day or who leave against medical advice
Individuals with significant post-acute needs beyond the scope of the program such as
- major trauma
- active cancer treatment
- unstable mental illness
- active substance abuse
- long-term hyper-alimentation
What hospitals are participates in ComPass2C?
Nine hospitals in the Eastern and North Central Connecticut arc supporting and partnering with CCC1 to o^
John Dempsey Hospital at UConn Health Center
Lawrence & Memorial Hospital
MidState Medical Center
Saint Francis Hospital & Medical Center
The Hospital of Central Connecticut
The William W. Backus Hospital
What are the anticipated benefits of tbeComPass2C program?
On an individual level, care transition coaching gives individuals and their families the tools and skills to be more comfortable and confident in their overall care. From a systems prospective, the goal is to improve transition communication and supports between hospitals, post-acute care organizations, primary care providers, specialists and community based organizations. This should result in improved quality of life for those served, fewer readmissions and measureable savings to the Medicare program
About Connecticut Community Care, Inc. (CCCI)
CCCI identifies choices and provides services to support people of all ages, abilities and incomes to live at home. The non-profit care management organization is an access agency to the CT Home Care Programs (CHCP) and to the Money Follows the Person (MFP) program in 124 towns the North Central, Northwest and Eastern CT. It also operates a private division, Care Management Associates, which serves others statewide who do not qualify for the CHCP or MFP. CCCI serves more than 13,000 individuals and their families each year through regional offices located m Wethersfield, Watertown and Franklin. The Corporate Office is located in Bristol
ComPast2C administrative office location:
43 Enterprise Drive
Bristol, CT 06010
Toll-free phone: 1-866-845-2224