Connected Care Ohio is a telehealth program through the Western Reserve Area Agency on Aging (WRAAA) that focuses on case management, the transition of care, health coaching, and community linkages. The program aims to reduce health disparities and monitor health conditions to avoid unnecessary emergency room visits and hospital admissions.

How the Connected Care Telehealth Program Works           

When a patient signs up for the program, the patient will receive, based on their need, at no cost, a blood pressure cuff, a thermometer, an oximeter, or a scale. In addition, the assigned Clinical Care Coordinator will be able to assist with monitoring the patient’s vitals and provide coordination with medical professionals.  

Program Eligibility Requirements

1. Medicare Part B
2. Two chronic conditions expected to last more than six month

Services

Case Management

The program will assist members with multiple chronic conditions and frequent emergency room and hospital use. WRAAA Clinical Care Coordinators will coordinate care, manage transitions between levels of care, and work collaboratively with all providers to identify the best care plan possible. Areas of focus will include addressing members' psychosocial barriers to health condition improvement, medication compliance, and member goals, resulting in decreased emergency room visits and hospital utilization.

Transition of Care

Assists members to ensure care is uninterrupted when moving between care settings or to the home. Care settings may include hospitals, mental health facilities, substance use treatment facilities, skilled nursing facilities, long-term care facilities, rehabilitation facilities, and correctional facilities. Areas of focus include coordination of services, reviewing discharge plans, and possibly connecting members to longer-term care management programs.

Health Coaching

Helps members at risk for or diagnosed with adult and pediatric asthma, congestive heart failure, diabetes, and COPD. Health Coaches provide members with education, coaching, and support to help them understand and manage their conditions.

Community Linkages

Assists members by addressing social determinants that have an impact on member health. The Clinical Care Coordinator provides care coordination and referral services to members requiring navigation assistance and access to plan and community-based benefits and resources.

Remote Patient Monitoring (RPM)

Helps the care team monitor chronic conditions outside of the traditional healthcare environment and intervene in disease management as necessary. The data generated through RPM helps facilitate conversations between patients and providers around the impact of disease and response to treatment and provides opportunities to intervene more quickly when health conditions worsen. RPM provides faster and easier access to healthcare services for patients, all from the safety and comfort of their homes.

To make a referral, please complete and submit this form.

To make a referral, email: connectedcare@areaagingsolutions.org for assistance or call: 216-727-2852.