Year One Report released for the Care Transitions of WNY

News from Aging, Posted on Wed, 08/14/2013 - 3:00pm

The Cattaraugus County Department of the Aging is pleased to announce the release of the Care Transitions of Western New York Coalition Year One Report. The report details the major milestones achieved since the coalition first launched efforts to improve patients’ transition from hospital to home.

Under the leadership of the P2 Collaborative of Western New York, Care Transitions of Western New York brings together hospitals and community-based organizations (CBOs) to reduce the number of avoidable hospital re-admissions. During the first year of the program, the coalition provided coaching services to more than 280 Medicare fee-for-service beneficiaries across seven participating counties in Western New York (Allegany, Cattaraugus, Chautauqua, Genesee, Niagara, Orleans and Wyoming). In Cattaraugus County, the Department of the Aging/NY Connects is partnering with Olean General Hospital on this initiative.

The report notes that in the face of many challenges – limited numbers of eligible patients, staffing shortages, system obstacles, and the ever-changing health care landscape – the community-based organizations and hospitals working together on this initiative have gained great traction with the program. Coaching capacity was expanded, relationships between a variety of participants were nurtured, and patient success was observed.

Cathy Mackay, director of the Cattaraugus County Department of the Aging, states that the Care Transitions program in Cattaraugus County has helped to bridge the gap between medical and community based in-home services. “Quite often people go home from the hospital with referrals for multiple contacts and services. It can be a confusing time of transition. With the Care Transitions Initiative, the Department of Aging/NY Connects worker sees the person first in the hospital and then follows up with them after discharge to answer their medication questions, give options for meeting future medical or non-medical needs, and set up any other services.”

With the foundation of the program laid, the Care Transitions of Western New York Coalition will move forward into Year Two with its sights set on a number of program enhancements.

For a copy of the report or more information regarding the Care Transitions of Western New York Coalition, please contact the Cattaraugus County Department of the Aging at 716-373-8032 or 1-800-492-2901. The report can also be found online at There will also be a public webinar on Tuesday, September 10th at 12:00 pm for those interested in learning more about the report. You can register for the webinar here:

News from Aging

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