2024 Care Transitions ECHO Series
2024 Care Transitions ECHO Series
The HHS Administration for Community Living (ACL) hosted a learning collaborative entitled "Building Partnerships to Support Health-Related Social Needs" and brought together hospitals, health systems, accountable care organizations (ACOs), and community based organizations (CBOs). This ECHO series focused on collaborative approaches to screening for health related social needs (HRSNs), connecting with community based services, and supporting hospital transitions.
The eight ECHO series topics and descriptions are listed below.
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2024 ECHO Series Curriculum Guide
This ECHO Series curriculum document includes a session overview and links to speaker presentations (available via YouTube). Additionally, supporting resources are provided to supplement speaker content.
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Series Conclusion and Future Developments
In this concluding session, we reviewed upcoming policies relevant to care transitions work, explored how to use Medicaid and administrative claiming to support transition activities, and highlighted opportunities to strengthen community partnerships. This session also featured brief presentations from invited participants and partners to celebrate their contributions, successes, and discuss their plans to continue growing their partnership.
Closing the Loop with Medicare Part B Providers
This session focused on “closing the loop” for care transitions by connecting Medicare Part B providers with community based organizations (CBOs), emphasizing the vital role CBOs play in supporting post-discharge follow-up and service delivery. Speakers also provided an overview of the Physician Fee Schedule rules, coding, and billing.
Concurrent Billing
This session focused on payment pathways to bill for transition activities and provided an overview of Transitional Care Management, Chronic Care Management (TCM/CCM) and Community Health Integration (CHI) service codes. This session also explored how healthcare providers and community based organizations (CBOs) could leverage billing for transition activities.
Short & Long-Term Supports – CBOs and Providers
This session focused on billing and reimbursement and the importance of communication in sending as well as receiving referrals to close the loop and provide effective and sustainable post-discharge services. This session also explored how community based organizations (CBOs) can support healthcare partners, align electronic medical records (EMR) and data, and meet Part A and Part B billing requirements.
Methods of CBO Engagement for People in Transition
This session explored how to navigate the discharge process and build partnerships with community based organizations (CBOs) to address unmet social needs. Partnerships learned about the importance of coding interventions for referrals, documentation, and billing, as well as how hospitals and CBOs can share responsibility and revenue to support successful transitions.
Communication Pathways
This session focused on how to optimize communication in the health related social need (HRSN) screening and discharge process using the TEAMS STEPPS framework. Participants learned how to prevent communication breakdowns, integrate Community Health Integration (CHI) and Principal Illness Navigation services, and improve referral workflows. The featured case study highlighted how a hospital and community based organization (CBO) network streamlined communication for better service delivery post-discharge.
Screening for Health-Related Social Needs
This session covered health related social need (HRSN) screening requirements, best practices in documenting social needs, and tools to collaborate with community based organization (CBO) partners. Through a case study, participants learned about how to make successful referrals, ensure follow-up, and close the loop for individuals transitioning from hospital to the community.
Impact of Social Needs on Care Transitions
This session introduced the ECHO series, focusing on the importance of addressing social needs through current policies such as the Joint Commission requirements, health related social need (HRSN) screening, and FY 2024 rules. This session also featured a case study on hospital and community based organization (CBO) collaboration, providing participants with a customizable workflow for best practice in addressing social needs. This initial session laid the foundation for peer learning to drive progress in partnership development and care transitions throughout the series and beyond.
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Contact Us
To contact the ACL/Technical Assistance team, please email: CareTransitions@acl.hhs.gov