Care Transitions Community

Welcome to the Care Transitions community! Users can find resources related to Care Transitions.

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Care Transitions Community Resources

These resources can help NWD Systems, community-based organizations and healthcare partners to begin or grow their Care Transitions programs. Users can access a Care Transitions Toolkit, past Care Transitions ECHO learning series materials, join discussions, and get information on Care Transitions events.

Care Transitions Discussion Board

The Care Transitions Discussion Board is here for all to pose care transitions questions, share resources for care transitions programs, and discuss issues with peers and the ACL Care Transitions team.

10 discussions Active 1 yr ago

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.

2024 ECHO Series Curriculum Guide Series Conclusion and Future Developments Closing the Loop with Medicare Part B Providers Concurrent Billing Short & Long-Term Supports – CBOs and Providers Methods of CBO Engagement for People in Transition Communication Pathways Screening for Health-Related Social Needs Impact of Social Needs on Care Transitions

1 topic Active 2 mths ago

2023 Care Transitions ECHO Series

Resources and recordings of the Care Transitions ECHO Series: Strengthening Partnerships to Support Hospital Transitions ECHO Series

CT ECHO Office Hour 3 CT ECHO Session 3 CT ECHO Office Hour 2 CT ECHO Session 2 CT ECHO Office Hour 1 CT ECHO Session 1 External Care Transitions Resources of Interest

2 topics Active 1 yr ago

Care Transitions Resources

The ACL Care Transitions team has developed and compiled multiple care transitions resources from various sources available here. These resources are designed to shard best practices and provide guidance for any organization to establish a new care transitions program or enhance an existing program.

17 articles Active 6 mths ago

Care Transitions Toolkit

All six chapters of ACL's Care Transitions Toolkit, initially developed in 2012, has been posted here to provide guidance to the aging network on how to begin or establish care transitions programs. It has been supplemented with additional resources to offer current examples of resources including the disability network and the current realities of the COVID-19 pandemic.

7 articles Active 1 yr ago

Care Transitions Webinars

The ACL Care Transitions team has hosted numerous webinars sharing care transitions best practices and highlighting innovative programs across the NWD network.

Care Transitions Peer Hour - Hospital to Home Care Transitions Peer Hour - Institutional Care Transitions Peer Hour - AL's Partnerships Care Transitions November Office Hours Care Transitions November Special Session Care Transitions December Peer Hour Care Transitions March Peer Hour May 2020 Care Transitions Office Hours

34 topics Active 3 yrs ago

Money Follows the Person Resources

The Money Follows the Person (MFP) demonstration supports state efforts for rebalancing their long-term services and supports system so that individuals have a choice of where they live and receive services. These resources share information about the legislation behind MFP, as well as the benefits that can be achieved through partnerships between NWD and MFP programs.

4 articles Active 3 yrs ago

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Contact Us

To contact the ACL/Technical Assistance team, please email: CareTransitions@acl.hhs.gov