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"A common arrangement is for Area Agencies on Aging (AAAs) to operate CTI programs and receive referrals from hospitals or health plans. Some AAAs have contracts with hospitals or health plans that pay for the work of the Transitions Coach, while others receive funding through the Older Americans Act or foundation grants. In addition, some health plans, home health agencies, community-based organizations, and educational institutions employ their own Transitions Coaches to serve patients or members."

Care Transitions Intervention: Coaching Patients to Successfully Transition from Hospital to Home | Playbook Highlights the Care Transitions Intervention (CTI), an evidence-based, short-term model that helps prevent unnecessary hospital readmissions and emergency department visits and reduce unnecessary spending.

The Critical Role of Area Agencies on Aging in Addressing the Health-Related Social Needs of Older Adults | Playbook Explores findings from the AAA National Survey conducted by n4a and Scripps Gerontology Center at Miami University, which shed light on the wide range of needs that AAAs address in their communities, as well as the expertise their staff bring to meet those needs.