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. Due to infection control concerns at nursing facilities, hospitals discharge many individuals to the community and there is an emergent need to rely on community-based organizations (CBOs) to support transitions of care. As a result, CBOs providing care transitions services have a heavy emphasis on hospital-to-home transitions and nursing home diversion activities. This document includes tools the aging and disability network can use to better facilitate these transitions.

Keyword(s): resource guide; CBOs; transition services; assisted living facilities; policy; partnership building