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.

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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

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.

1 discussion Active 5 mths ago

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.

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

Discussions and resources related to the third Care Transitions ECHO Office Hour

CT ECHO Session 3

Discussion and resources related to the third Care Transitions ECHO Session

CT ECHO Office Hour 2

Discussions and resources related to the second Care Transitions ECHO Office Hour

CT ECHO Session 2

Discussions and resources related to the second Care Transitions ECHO Session

CT ECHO Office Hour 1

Discussions and resources related to the first Care Transitions ECHO Office Hour

CT ECHO Session 1

Discussions and resources related to the first Care Transitions ECHO Session

External Care Transitions Resources of Interest

Resources and materials shared from webinars, learning communities, and other initiatives related to Care Transitions

2 discussions 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.

16 articles Active 10 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

Materials related to the Care Transitions - Hospital to Home call held on September 8, 2020.

12 articles Active 4 yrs ago

Care Transitions Peer Hour - Institutional

Materials related to the Care Transitions - Institutional Transitions call held on September 15, 2020.

3 articles Active 4 yrs ago

Care Transitions Peer Hour - AL's Partnerships

Materials related to the Care Transitions - Alabama's Partnerships call held on October 22, 2020.

8 articles Active 4 yrs ago

Care Transitions November Office Hours

Materials related to the Care Transitions November Office Hours call held on November 10, 2020.

1 article Active 4 yrs ago

Care Transitions November Special Session

Materials related to the Care Transitions November Special Session call held on November 19, 2020.

1 article Active 4 yrs ago

Care Transitions December Peer Hour

Materials related to the Care Transitions December Peer Hour - Michigan Hospital Transitions call held on December 1, 2020.

4 articles Active 4 yrs ago

Care Transitions March Peer Hour

Materials related to the Care Transitions March Peer Hour - Role of CBOs in Addressing SDoH call held on March 31, 2021.

1 article Active 3 yrs ago

May 2020 Care Transitions Office Hours

Materials related to the ADRC/NWD System COVID-19 response grant office hours on care transitions held on May 2020.

4 articles Active 4 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