Here is today’s Monday Mailer for you:

HSRC Webinar

The Housing and Services Resource Center (HSRC) is hosting a webinar on  “Lessons Learned from the Housing & Services Partnership Accelerator” on July 29, from 2:00-3:30 PM ET. This webinar will introduce the new Partnership Toolkit, a resource designed to help states and community partners develop and strengthen cross-sector partnerships across aging, disability, health, and housing systems. The toolkit is informed by lessons learned from HSRC’s 2024 and 2025 Housing & Services Partnership Accelerator (HSPA). HSPA supported 12 state teams in strengthening cross-system partnerships to improve access to housing services for older adults and people with disabilities. Team leads from Michigan, Arizona, and New Hampshire will share how cross-sector partnerships support housing stability for older adults and people with disabilities. Register here.

Person-Centered Practice Webinar Slides

The Person-Centered Practice Knowledge, Skills, and Abilities for Community Care Hubs Webinar highlighted two resources that define the essential knowledge, skills, and abilities frontline community-based service providers need to effectively deliver person-centered support. View the slides here.

Three Critical Moments in Every Care Transition

Effective care transitions extend beyond the point of hospital discharge and require coordinated support across three critical phases: pre-discharge, in-hospital discharge planning, and post-discharge. Each phase presents an opportunity for community-based organizations (CBOs) and healthcare providers to work together to improve continuity of care and support successful transitions back to the community.

During the pre-discharge phase, organizations can identify whole person health needs, engage individuals and family caregivers, and begin planning for services before discharge. Resources such as the ACL No Wrong Door ECHO Series webinar on Screening for Health-Related Social Needs provide additional strategies for identifying needs that may impact care transitions. During hospital discharge planning, CBOs coordinate with healthcare teams to arrange transportation, home and community-based services, medications, and other supports needed for a safe transition home. This phase is often the point at which medical recommendations are translated into a coordinated plan for community-based services and supports, with resources such as this Teach-Back Interactive Learning Module and the ACL No Wrong Door ECHO Series webinar on Communication Pathways highlighting approaches for strengthening communication among individuals, caregivers, healthcare providers, and communication partners. In the post-discharge phase, follow-up, care coordination, and ongoing support help address emerging needs, reinforce care plans, and reduce the likelihood of hospital readmissions.

By engaging at each transition point, CBOs can help bridge the gap between clinical care and the community-based supports individuals need to maintain their health, independence, and quality of life after hospitalization, as highlighted in the ACL No Wrong Door ECHO Series webinar on Short and Long-term Supports for CBOs and Providers.

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We hope you find these resources helpful! See you next Monday!