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