Eastern Virginia Care Transitions Partnership 

EVCTP 

ACL Business Acumen Learning Collaborative

January 29th, 2014 

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Eastern Virginia Care Transitions Partnership: 

A community partnership of health systems, area agencies on aging, independent 

physicians’ groups and other public and private health and human service providers.

AREA AGENCIES ON AGING 

Bay Aging – Lead Community Based Organization 

Eastern Shore Area Agency on Aging and Community Action Agency, Inc. 

Peninsula Agency on Aging, Inc. 

Senior Services of Southeastern Virginia 

MANAGED CARE ORGANIZATIONS 

HEALTH SYSTEMS 

Bon Secours 

Mary Washington Healthcare 

Rappahannock General Hospital 

Riverside Health System 

Sentara Health Care 

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EVCTP Hospitals and LCO Regions

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EVCTP Organization 

Bay Aging 

Lead Community Based 

Organization 

Senior Services of 

Southeastern Virginia 

Board 

CEO 

Peninsula Agency on Aging 

Board 

CEO 

Eastern Shore Agency on 

Aging 

Board 

CEO 

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Bay Aging 

Planning Districts 17 and 18 

 Lead Community Based Organization (CBO) 

 Fiduciary Agent for EVCTP 

 Technology Provider for EVCTP 

 Housing, Medicaid Home Care, Public Transit 

 Community Action Agency 

 Aging and Disability Resource Center 

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Eastern Shore Area Agency on Aging

& Community Action Agency, Inc. 

Planning District 22 

Medicaid Home Care Provider 

Community Action Agency and AAA 

Head Start and Weatherization Operator 

Aging and Disability Resource Center 

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Peninsula Agency on Aging 

Planning District 21 

 

 Care Coordination Innovator 

 Leading Aging Planning Agency in PSA 

 2013 n4a Excellence In Leadership Award 

 Aging and Disability Resource Center 

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Senior Services of Southeastern Virginia 

The Center for Aging 

Planning District 20 

EVCTP Evidence Based Training Provider 

 2013 Change Leader Award Winner 

 Transit, Housing, Center for Aging 

 Aging and Disability Resource Center 

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Privacy, Confidentiality, Security: 

Required of all EVCTP Members 

• All patient information protected and not divulged 

• All patient information securely stored at all times 

 whether digital or physical 

• Any proprietary partner information considered 

 confidential unless otherwise agreed to in writing 

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Secure 

Information 

Flow & Storage 

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EVCTP Bench Strength

FISCAL INTEGRITY: 

• UNQUALIFIED independent third party audits 

• $34 million Combined Budget 

• 14% Average Indirect Costs 

GEOGRAPHIC AND POPULATION REACH: 

• 6,300 square miles 

• 26 Cities and Counties 

• 415,000 65+ Population by 2030 

STAFFING CAPACITY: 

• 600 employees and $12.6 million payroll 

• 200 employees working within Case Management/Assessment Staffing 

• Nurses, Social Workers, Intake Specialists, Consumer-Directed Options 

 Counselors, Certified Coaches, and Administrative Staff 

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EVCTP Bench Strength

EXPERIENCE: 

• 155 years of service working with other public and private providers 

• 41 years of billing, reporting and maintaining quality records 

• National Provider Identifiers and Atypical Provider Identifiers available for the State 

• Medicaid Agency and CMS 

• Secure IT referral, reporting and billing systems for State Medicaid and CMS 

SERVICES – FY2012: 

• Performed 1,500 intakes using Uniform Assessment Instrument 

• 170 Adult Day Health Services clients; unlimited capacity 

• 631,000 meals 

• 403,000 hours of personal care 

• 40,200 hours of respite care; 

• Unlimited capacity for direct and referred services 

• 300,000 trips: 98,500 medically related; 

• 1,000 Home modification and repairs 

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Services Available through EVCTP: 

Options Counseling Home Delivered & Congregate Meals

In-Home Care Transportation

Home Repairs Care Coordination for the Elderly 

Adult Day Health Services Mobility Management

Veterans Home & Community Services Chronic Disease Self-Management 

Insurance Counseling & Medicare Part D Senior Employment

Money Follows the Person Senior Centers

This list is not inclusive of all services provided by the agencies. However, this list 

does represent services having a major impact for older Virginians annually. 

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Care Transitions Using the Coleman Model 

• EVCTP AAAs use transitional 

coaching fo reducing readmissions 

using the Coleman model – Four 

Pillars of Care Transitions 

• Coaches are professionally trained 

and certified through the Coleman 

Institute Developed by Eric A. 

Coleman, M.D., M.P.H. 

A proven, evidence-based 

model of reducing 

hospital readmissions. 

Medication Self-Management 

where patient becomes knowledgeable 

about medications and has a medication 

management system. 

Dynamic Patient-Centered Record 

 so patient understands/uses a Personal 

Health Record to improve 

communication with primary care 

provider and specialist. 

Follow-Up patient schedules and 

completes follow-up visit with primary 

care provider/specialist. 

Red Flags alerts patient about 

indications that condition is getting 

worse and how they should respond. 

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RESULTS COUNT! In-Home Pilot Project:

• 2011 – Partnered with hospitals to improve hospital to home patient 

 outcomes 

• Goal - Reduce hospital readmissions for Dual Eligible (Medicare/Medicaid) 

 people 60 years and over and nursing home eligible 

• Included enhanced services to improve quality of life – transportation, 

 Meals on Wheels, chore services and other supports, advanced care 

 planning supports 

• Outcomes - 

• 265 patients referred 

•2 readmissions within 30 days of discharge 

98.6% 

averted 

Veterans Directed Home and Community Based Services – 37 of 38 people averted 

Adult Day Health Services (day care) – 72 of 73 people averted 

Provide Financial Management System to process payroll for client-directed (employer) services 

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Eastern Virginia Care Transitions Partnership 

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Eastern Virginia Care Transitions Partnership 

Diana Giles, CFO 

Bay Aging 

P.O. Box 610 

5306 Old Virginia Street 

Urbanna, Virginia 23175 

804.758.2386

dgiles@bayaging.org www.bayaging.org

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