Transitional Care

Need help with a chronic condition, or after a discharge to home?


Transitioning Home

Transitioning from a hospital or nursing home, back to the comfort of your own home is a welcome change. However, it often comes with a number of challenges that can hinder your success and safety. WRAAA is committed to helping our consumers achieve the best possible medical outcomes while remaining in community-based home settings. We want to help get you back home through either our Transitional Care programs, Anthem or Medical Mutual of Ohio. 

  • Transitional Care– Designed for patients transitioning from hospital to home
Ohio's HOME Choice:

HOME Choice is a transition program that assists individuals age 18 and older to move from a long-term care facility, (e.g. nursing facility, hospital, or ICF-IID) into a home and community-based setting. Once Medicaid eligibility is established, WRAAA staff is able to conduct a needs assessment.



  • Be enrolled in Medicaid
  • Be 18 years of age or older
  • Have income to sustain community living
  • Participate in a needs assessment and have a need for the program
  • Have care needs that can be adequately met in a community setting
  • Lived in a Medicaid certified facility for at least 90 consecutive days

If you are interested in HOME Choice services, call the Ohio Department of Medicaid Home Choice Bureau at (888) 221-1560 or visit the Ohio Department of Medicaid website.

ransition Care: 
For patients transitioning from hospital to home

Transitioning from hospital to home is a vulnerable time, often overwhelming and confusing. To help with that transition, members will be matched with a Transition Health Coach to assist with follow-through and discharge instructions, empower the member to create personal health goals, review medications and identify areas of concern or discrepancy, and encourage collaboration between the member and Primary Care Physicians.

WRAAA partners with our area Health Plans to provide the Transition Care intervention (using the Care Transition Intervention model) to members across Ohio, bridging the gap between members and providers by focusing on the transition from hospital to home. The goal of the Program is two-fold:

  • To promote member empowerment and improve compliance during a hospital-to-home transition
  • To prevent potentially avoidable hospital readmissions by working with members to ensure follow up appointments are met, medication reviews are completed, red flag symptoms are identified, and a personal health care record is created.

Successful Outcomes

WRAAA has been successfully helping transition members from institutional settings to home and community-based settings since 2015. And, since 2018, with a 30-day intervention, we have transitioned over 1300 patients from hospital to home resulting in reduced readmission rate from 12% to 7%. These results speak to less stress for members with improved outcomes and cost-saving.

Notice of Privacy Policy

Health Information Exchange; Western Reserve Area Agency on Aging, in partnership participates in Health Information Exchange where your information can be shared and accessed by other entities involved in your treatment, payment for services, or healthcare operations. CliniSync is the Health Information Exchange in which WRAAA participates. You may opt-out of CliniSync Health Information Exchange at any time by providing written notice to us by either emailing it to:; faxing it to: (216) 472-8782  or mailing it to: 1700 E. 13th. St., Cleveland, OH 44114, Attention: Sr. Compliance and Privacy Officer. We may be required to disclose your information, even when you opt-out, for limited purposes such as public health reporting or as required by Law.


HOME Choice Program

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Transitional Care Services

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Business Partner Inquiries

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