-
ACL: Disability and Aging Partnerships in No Wrong Door
A state’s No Wrong Door System is designed to serve all populations who may need long-term services and supports (LTSS), regardless of payer. This includes older adults,…
-
November 4, 2024
Here is today’s Monday Mailer for you: Caregiver Corner November is National Family Caregivers Month! Read President Biden’s proclamation here. With support from ACL, ten states (AK, CA, IN, MO, NC,…
-
Health Equity Services in the 2024 Physician Fee Schedule Final Rule
Medicare Learning Network Booklet: Health Equity Services in the 2024 Physician Fee Schedule Final Rule
-
Understanding How Social Care Programs Impact Health
Social risk screening and navigation programs in health care systems across the United States have expanded rapidly, spurred in part by changes in federal and state policies related to health-related…
-
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
-
2023-2024 Care Transitions: Building Partnerships to Support Health Related Social Needs
The HHS Administration for Community Living (ACL) invited hospitals, health systems, Accountable Care Organizations (ACOs) and community-based organizations (CBOs) to a special series of learning…
-
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…
-
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…
-
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,…
-
AoA: Care Transitions Toolkit - Chapter Four: Measuring for Success
This chapter provides information comparing evaluation to performance measurement, the importance of planning ahead; types of care transitions measures; process and structural measures;…
-
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 ·…
-
ACL: State Examples of NWD Funding
Description: This document provides examples of how NWD Systems can use a variety of funding streams to support development and sustainability. The section titled "Hospital Systems" offers an example…
-
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…
-
CTI: September 2020 Care Transitions Intervention (CTI) Webinar Materials
Description: The attached materials are related to the Care Transitions Intervention (CTI) webinar held on September 11, 2020. The materials include a downloadable recording of the webinar,…
-
ACL: COVID-19 Care Transitions Spotlight: Western New York Integrated Care Collaborative, Inc.
Description: This spotlight on the Western New York Integrated Care Collaborative, Inc. (WNYICC) provides information on the work they are doing to sustain their care transitions program before and…
-
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…
-
RTC: People with Disabilities Still at Risk in Congregate Care Settings Brief
Description: "People with Disabilities Still at Risk in Congregate Care Settings" summarizes CMS data at county and regional levels to inform community response to the recent increases in COVID-19…
-
Federal Healthcare Resilience Taskforce: Alternate Care Site Toolkit
This toolkit provides medical operations guidance for state, local, tribal, and territorial entities on operationalizing alternate care sites during the COVID-19 pandemic.…
-
RIC: Key Considerations For Health Plans: Partnering With Community-Based Organizations To Address Social Determinants Of Health
Description: Resources for Integrated Care (RIC), in collaboration with The SCAN Foundation, has developed a brief on key considerations for health plans interested in working with CBOs to address…
-
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…
-
ADBI: Health Care Outreach Toolkit
Description: This toolkit from the Aging and Disability Business Institute (ADBI) offers guidance for aging and disability community-based organizations (CBOs),…
-
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…
-
Iowa: Progress Report on the Pilot Initiative to Provide Long-Term Care Options Counseling – Iowa Return To Community
Description: This report was compiled by the Iowa Department of Aging to detail the progress of the Iowa Return to Community (IRTC) Initiative, a pilot initiative to provide long-term care options…
-
ACL: COVID-19 Care Transitions Spotlight: Southern Alabama Regional Council on Aging
Description: This spotlight on the Southern Alabama Council on Aging (SARCOA) provides information on their non-profit corporation, Community Care Solutions (CCS),…