This chapter provides a definition and overview of care transitions, evidence-based models and how the aging network supports care transitions. Since the original care transitions toolkit publication in 2012, the Administration on Community Living (ACL) was created to support older adults and individuals with disabilities. Therefore, we provide current case studies below. Additionally, the COVID-19 pandemic forced ADRCs to quickly respond to the rapidly changing landscape of hospital and nursing facility transition. Though the network has traditionally leveraged evidence-based models, other models have been effective ways to meet this crisis.

Additional Resources

• COVID-19 Care Transitions Spotlight: Southern Alabama Regional Council on Aging 
• Care Transitions October Peer Hour
• ACL Care Transitions Website
• Federal Hospital Care Transitions Resources and the Aging and Disability Network
• NWD Podcast Episode #1
• Five Practical Ways ADRC/NWD Systems Can Reach Out to Nursing Facilities During the COVID-19 Pandemic

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