The Administration on Aging (AoA) developed a toolkit in 2012 to provide guidance to the aging network on how to begin or establish care transitions programs. Much has changed since that time including support from the Administration for Community Living (ACL) to strengthen a growing network of statewide No Wrong Door (NWD) Systems which serve all populations and payers.  For each of the chapters of the previous toolkit we have compiled corresponding additional resources provided to offer current examples of resources including disability networks and the current realities of the COVID-19 pandemic.  

Sustaining a NWD System requires a comprehensive strategy to blend various funding streams. Statewide NWD System governance, including the ability to diversify funding sources, comprises a key component of successful development and implementation of a mature NWD System.  NWD Systems use a variety of funding streams with the largest percentage (over 50 percent) coming from state and local funds (NWD Business Case Grantee Reporting, 2019).  Given the current landscape of tight state and federal budgets the ACL developed the Strategic Framework for Action which encourages blending and braiding of funding sources as well as expanding sustainability to include health systems as funding sources.

Care transitions activities are a critical part of a high-functioning NWD System. The NWD key elements outlines that NWD Systems must have formal relationships with entities where major transitions occur such as hospitals and nursing facilities as well as staff with the competencies to assist with transitions. Leveraging diverse funding must include finding a way to finance care transitions activities. This toolkit provides practical examples of how to initiate relationships with health care and social service providers to get reimbursed for care transitions activities.

The COVID-19 public health emergency led many health care providers, especially hospitals, to quickly plan how to address rising hospitalization rates, reduced bed capacity, and expedited discharges. Due to infection control concerns at nursing facilities, hospitals discharge many individuals to the community and there is an emergent need to rely on NWD Systems to support transitions of care. As a result, NWD Systems entities, including Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs), Centers for Independent Living (CILs), and other community-based organizations (CBOs) providing care transitions services have a heavy emphasis on hospital-to-home transitions and nursing home diversion activities. These services are an important tool to manage hospital surge capacity and to support people with nursing home level of care needs to live safely in the community.

ACL’s mission – supporting opportunities for community living and inclusion for all – has become all important during the COVID-19 pandemic to keep older adults and persons with disabilities safe from infection. As stated by Alison Barkoff, the Acting Administrator and Assistant Secretary for Aging, ACL has the responsibility to ensure “that the needs of older adults and people with disability are considered in the federal pandemic response”, including addressing social determinants of health and “the long-standing barriers faced by people with disabilities and older adults, especially people from communities of color and others who are marginalized.”[1] On March 11, 2021 President Biden signed the American Rescue Plan Act (ARPA) (H.R. 1319) into law. The final package included numerous provisions that offer opportunities for NWD Systems to leverage funding to support planning, implementation and sustainability. The funds granted by the ARPA provide additional opportunities for states to broaden the impact and reach of their efforts to establish new or build on existing relationships with hospitals, nursing homes, and additional health care providers.

The audience for this toolkit is local sites that are building up care transitions programs and working with health care partners. The content includes information about what care transitions is, how to start a program up, and how to sustain it for the long term. This toolkit will include information about how to adapt or utilize a program to meet pandemic circumstances and conduct emergency preparedness. 

• Chapter 1: Getting Started
• Chapter 2: Taking Time to Plan
• Chapter 3: Developing Effective Partnership
• Chapter 4: Measuring for Success
• Chapter 5: Building Operational Capacity
• Chapter 6: Implementation and Day to Day Operations

*If you would like a 508-compliant version of this document, please contact TA-Community@lewin.com.

[1] https://acl.gov/news-and-events/acl-blog/message-acting-administrator-and-assistant-secretary-aging-alison-barkoff