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Understanding How Social Care Programs Impact Health
Social risk screening and navigation programs in health care systems across the United States have expanded rapidly, spurred in part by changes in federal and state policies related to health-related…
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Understanding the Medicare Physician Fee Schedule Billing Codes - Partnership to Align Social Care
Understanding the Medicare Physician Fee Schedule Billing Codes for: Community Health Integration (CHI) Principal Illness Navigation (PIN) Principal Illness Navigation – Peer Support (PIN-PS) Service
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Transitional Care Management (TCM) and Chronic Care Management (CCM) Billing Codes for Community-Based Organizations (CBOs)
Transitional Care Management (TCM) and Chronic Care Management (CCM) Medicare billing codes allow for the billing of services that support Medicare patients with complex conditions post hospital…
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The Collaborative on Health Reform and Independent Living: COVID-19 and Transition Services in CILs
Description: This report describes findings from a 2021 survey of Centers for Independent Living (CILs) on care transitions. CILs were asked to compare the volume of pre-pandemic transitions…
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Indiana: D-SNP Care Coordination Orientation
Description: 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…
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Indiana: Care Transitions Program Pitch Deck for Hospitals
Description: 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…
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Indiana: Care Transition Process Flow
Description: Through an ACL NWD Business Case grant, Indiana demonstrated that 1) person-centered counselors help individuals access HCBS and avoid institutional care in a nursing facility;…
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Federal Healthcare Resilience Taskforce: Alternate Care Site Toolkit
This toolkit provides medical operations guidance for state, local, tribal, and territorial entities on operationalizing alternate care sites during the COVID-19 pandemic.…
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RTC: People with Disabilities Still at Risk in Congregate Care Settings Brief
Description: "People with Disabilities Still at Risk in Congregate Care Settings" summarizes CMS data at county and regional levels to inform community response to the recent increases in COVID-19…
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ADBI: Health Care Outreach Toolkit
Description: This toolkit from the Aging and Disability Business Institute (ADBI) offers guidance for aging and disability community-based organizations (CBOs),…
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ACL: COVID-19 Care Transitions Spotlight: Western New York Integrated Care Collaborative, Inc.
Description: This spotlight on the Western New York Integrated Care Collaborative, Inc. (WNYICC) provides information on the work they are doing to sustain their care transitions program before and…
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ACL: Federal Hospital Care Transitions Resources and the Aging and Disability Network
Description: The COVID-19 public health emergency led many hospitals to quickly plan how to address rising hospitalization rates, reduced bed capacity, and expedited discharges.…
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ACL: COVID-19 Care Transitions Spotlight: Southern Alabama Regional Council on Aging
Description: This spotlight on the Southern Alabama Council on Aging (SARCOA) provides information on their non-profit corporation, Community Care Solutions (CCS),…
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RIC: Key Considerations For Health Plans: Partnering With Community-Based Organizations To Address Social Determinants Of Health
Description: Resources for Integrated Care (RIC), in collaboration with The SCAN Foundation, has developed a brief on key considerations for health plans interested in working with CBOs to address…
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Iowa: Progress Report on the Pilot Initiative to Provide Long-Term Care Options Counseling – Iowa Return To Community
Description: This report was compiled by the Iowa Department of Aging to detail the progress of the Iowa Return to Community (IRTC) Initiative, a pilot initiative to provide long-term care options…
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CTI: September 2020 Care Transitions Intervention (CTI) Webinar Materials
Description: The attached materials are related to the Care Transitions Intervention (CTI) webinar held on September 11, 2020. The materials include a downloadable recording of the webinar,…
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Contact Us
To contact the ACL/Technical Assistance team, please email: CareTransitions@acl.hhs.gov