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Understanding the Medicare Physician Fee Schedule Billing Codes - Partnership to Align Social Care
Understanding the Medicare Physician Fee Schedule Billing Codes for: Community Health Integration (CHI) Principal Illness Navigation (PIN) Principal Illness Navigation – Peer Support (PIN-PS) Service
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Care Transitions: Building Partnerships to Support Health Related Social Needs
The HHS Administration for Community Living (ACL) is inviting hospitals, health systems, Accountable Care Organizations (ACOs) and community-based organizations (CBOs) to a special series of learning…
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Transitional Care Management (TCM) and Chronic Care Management (CCM) Billing Codes for Community-Based Organizations (CBOs)
Transitional Care Management (TCM) and Chronic Care Management (CCM) Medicare billing codes allow for the billing of services that support Medicare patients with complex conditions post hospital…
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Nevada: No Wrong Door Partner in Las Vegas Leverages Hospital2Home Care Transitions Model
Key partners: Nevada Senior Services – a No Wrong Door partner in Las Vegas, Nevada Valley Health System – an integrated system of care in Las Vegas and Southern Nevada comprised of six acute care…
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Partners in Care Presentation on Controlling Medication and SDOH-Related Readmissions Through HomeMeds 3.0 and Care Transitions
Partners in Care Foundation, a community care hub (CCH) in Sacramento, California, presented on their care transitions program during the May 10th, 2023,…
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Kansas: Aging and Disability Partners Work Together During COVID to Facilitate Transitions from Nursing Homes
Key Partners · Kansas Department of Aging and Disability Services (state unit on aging (SUA)) · Kansas Association of Area Agencies on Aging and Disability · Central Plains Area Agency on Aging ·…
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Do you currently offer or are you considering including care transitions services as part of your CCH service line?
Partners in Care Foundation recently shared an overview of their CCHs approach to bunding services. The PICF team has bundled their HomeMeds intervention with other care transition services to help…
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NLC Network Development Peer Group Dialogue Meeting 5/10/23
This Peer Group Dialogue meeting included a presentation from Partners in Care on establishing service lines. The presentation highlighted Partners in Care's HomeMeds program and Care Transitions.
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NLC Network Expansion Track Meeting 1/12/23
The second Network Expansion Track meeting focused on health and housing financing strategies. Please see meeting slides attached. Resources shared during the meeting:…
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New Hampshire: Care Transitions from Facility to Home During the COVID-19 Pandemic
Key Partners: ADRCs, hospital discharge planners, New Hampshire Care Collaborative The Aging and Disability Resource Centers (ADRCs) in New Hampshire (called ServiceLinks) have a long history of…
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Promoting Home and Community-based Services in Washington
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…
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AARP: LTSS Scorecard Website
Description: The Long-Term Services and Supports (LTSS) State Scorecard—a compilation of state data and analysis—showcases measures of state performance for creating a high-quality system of care in…
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North Dakota Care Transitions and Diversion Activities: Informed Choice Initiative
North Dakota is rolling out a large statewide initiative to expand access to home and community-based services (HCBS) by leveraging their Money Follows the Person (MFP) program and No Wrong Door…
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Care Transitions in Oregon's Aging and Disability Resource Centers
This resource describes the "who," "what," "how," and "where" of a hospital to home care transitions program led by the Multnomah County Aging and Disability Resource Center and Oregon Wellness…
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The Collaborative on Health Reform and Independent Living: COVID-19 and Transition Services in CILs
Description: This report describes findings from a 2021 survey of Centers for Independent Living (CILs) on care transitions. CILs were asked to compare the volume of pre-pandemic transitions…
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Indiana NWD Business Case: Person-Centered Counseling and Care Transition Intervention
Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need long term…
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Indiana: D-SNP Care Coordination Orientation
Description: Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need…
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Indiana: D-SNP Care Coordination Orientation
Description: Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need…
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Indiana: D-SNP Care Coordination Orientation
Description: Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need…
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Indiana: Care Transitions Program Pitch Deck for Hospitals
Description: Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need…
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Indiana: Care Transitions Program Pitch Deck for Hospitals
Description: Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need…
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Indiana: Care Transitions Program Pitch Deck for Hospitals
Description: Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need…
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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;…
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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;…
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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;…
ACL Technical Assistance Community
A collaboration space for No Wrong Door (NWD) community and partners