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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; and that 2) care transition coaches can help Indiana Aged and Disabled Medicaid Waiver participants avoid hospital readmissions and associated potential negative impacts on functional status, thus improving their ability to remain in the community.

The process flow describes how waiver care managers and hospitals will coordinate together, including the sharing of emergency room, hospital, or skilled nursing facility (SNF) admission and discharge data. It also includes procedures for actions and instructions on recording the services into the tracking system.

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