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Photo courtesy of Sunnyside Community Services

CommunityCare Link is part of a vibrant community of social service agencies working to partner with healthcare to improve health outcomes and lower costs in the care of older adults. For many years the Administration for Community Living (formerly the Administration on Aging) has worked to help its network of agencies around the country learn about opportunities in healthcare and improve the capabilities.

The effort started over 15 years ago with the incorporation of standards for evidence-based programming across the network, leading to the spread of programs like Matter of Balance, the Stanford Chronic Disease Self-Management Program, and Healthy Ideas. Since 2012, ACL launched its Business Acumen Initiative (BAI) to help those providers in the aging and disability networks.

Another important milestone was the Community-Based Care Transitions Program mandated in section 3021 of the Affordable Care Act in 2010. This provision funded a nation-wide demonstration of community-based organizations delivering post-hospitalization coaching and support to Medicare beneficiaries discharged from the hospital. Multiple agencies in the New York City area participated in the program and used the opportunity to deepen their understanding of health care systems and to prove their ability to move important metric’s such as 30 day readmission.

The results of this movement are also being captured and shared through the National Association of Area Agencies on Aging (N4A) and its Aging and Disability Business Institute.

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