Key Partners: ADRCs (CLCs), hospitals, IT vendor, Rush University CHASI (Bridge Care Transitions Model)

Washington state continually innovates to promote access to home and community-based services and supports. The Aging and Disability Resource Centers - ADRCs (named Community Living Connections – CLCs in Washington) provide services and supports to older adults and individuals with disabilities to maintain independence in the community.  One way the state’s NWD System is accomplishing this is through the Care Transitions program.  Care Transitions provides diversion of individuals from nursing facilities as well as hospital-to-home transitions.  After successful launch of the Care Transitions program through a few CLCs, funded in part by the NWD Business Case Development grant, these services are now being expanded state-wide. 

During the COVID-19 pandemic, the majority of Washington’s CLCs participated in hospital surge work using federal relief dollars in conjunction with other state funding.  The local agencies, either (1) expanded on existing programs, or (2) worked on developing new partnerships and referral protocols with local acute hospitals directly, or (3) coordinated as needed with the local Home and Community Services (HCS) regional office referral protocols to accept referrals for acute care discharge and assist with and support care transitions from hospital to home.  These referrals also included those from HCS for clients that do not qualify for Medicaid LTSS, but still require care transitions assistance.  Activities were tailored by the individual CLCs to meet their unique local needs.  CLCs who identified some best practices have been mentoring those who have experienced some challenges with the development of Care Transitions statewide. Statewide CLC’s have developed and enhanced relationships with local hospitals to sustain this work and have each engaged with hospitals within their service area and are continuing to build those partnerships. 

Washington state has chosen to engage with the Bridge Care Transitions model developed through the Center for Health and Social Care Integration (CHaSI) at Rush University.  This evidence-based model meets the needs of state due to social work focus and training availability for an ever-changing workforce.  While CLC’s have historically used a variety of methodologies, all will be participating in the Bridge trainings and will have the option of adopting this model.  The state has invested funds to provide this Bridge model training to designated CLC staff providing care transitions.  The Bridge assessment has already been customized and built into the state’s NWD information technology system, CLC-GetCare, developed by RTZ Associates. 

Washington also works with RTZ Associates for their NWD public searchable website and client tracking. The website provides (1) information about LTSS options and the NWD System, (2) a searchable resource directory using the Alliance for Information and Referral Systems LA/211 Taxonomy with ADRC filter, as well as (3) the means to directly contact local organizations. Google Analytics is used to develop reports on the number of visitors, where they come from, and how they use the site.  Washington has invested in modifications to the consumer website and in collecting data to improve local outcomes.

Washington has also invested heavily in family caregivers as a way to promote HCBS.  See more at: https://www.nashp.org/washington-demonstrates-cost-savings-and-improved-outcomes-from-supporting-family-caregivers/.