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Nevada: No Wrong Door Partner in Las Vegas Leverages Hospital2Home Care Transitions Model
Key partners: Nevada Senior Services – a No Wrong Door partner in Las Vegas, Nevada Valley Health System – an integrated system of care in Las Vegas and Southern Nevada comprised of six acute care…
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Kansas: Aging and Disability Partners Work Together During COVID to Facilitate Transitions from Nursing Homes
Key Partners · Kansas Department of Aging and Disability Services (state unit on aging (SUA)) · Kansas Association of Area Agencies on Aging and Disability · Central Plains Area Agency on Aging ·…
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New Hampshire: Care Transitions from Facility to Home During the COVID-19 Pandemic
Key Partners: ADRCs, hospital discharge planners, New Hampshire Care Collaborative The Aging and Disability Resource Centers (ADRCs) in New Hampshire (called ServiceLinks) have a long history of…
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Promoting Home and Community-based Services in Washington
Key Partners: ADRCs (CLCs), hospitals, IT vendor, Rush University CHASI (Bridge Care Transitions Model) Washington state continually innovates to promote access to home and community-based services…
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North Dakota Care Transitions and Diversion Activities: Informed Choice Initiative
North Dakota is rolling out a large statewide initiative to expand access to home and community-based services (HCBS) by leveraging their Money Follows the Person (MFP) program and No Wrong Door…
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Care Transitions in Oregon's Aging and Disability Resource Centers
This resource describes the "who," "what," "how," and "where" of a hospital to home care transitions program led by the Multnomah County Aging and Disability Resource Center and Oregon Wellness…
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Linking Technology to Address the Social and Medical Determinants of Health for Safe Medicines Use - Journal of Patient Safety
Combined analysis of data from 2 novel decision support programs yielded complementary findings that together address both medical and social determinants of health.…
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Indiana NWD Business Case: Person-Centered Counseling and Care Transition Intervention
Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need long term…
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OK NWD and MFP Partnership
Key Partners: State Medicaid agency, ADRCs, ombudsmen Oklahoma used CARES Act funds to contract with the 11 ADRCs that house the Ombudsman program. The contracts solidified a partnership with the…
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MD Blending and Braiding of Funding
Maryland plans to divert individuals from nursing facilities at the point of hospital discharge through strategic partnerships between the ADRC and local hospitals.…
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To contact the ACL/Technical Assistance team, please email: CareTransitions@acl.hhs.gov