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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;…
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CMS: Early Use of Community-Based Long-Term Services and Supports and Lower Downstream Use of Institutional Care Slide Deck
Description: This slide deck presented by CMS on June 7th, 2018 includes information and data on a study conducted to examine if community-based LTSS can lead to decreased usage of institutional…
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OK NWD and MFP Partnership
Key Partners: State Medicaid agency, ADRCs, ombudsmen Oklahoma used CARES Act funds to contract with the 11 ADRCs that house the Ombudsman program. The contracts solidified a partnership with the…
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MD Blending and Braiding of Funding
Maryland plans to divert individuals from nursing facilities at the point of hospital discharge through strategic partnerships between the ADRC and local hospitals.…
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AARP: Effective Transitions between Care Settings
Description: This brief details six ways states can measure and improve their care transitions programs between acute and long-term services and supports settings.…
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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…
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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),…
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Lewin Group: Money Follows the Person Demonstration Legislation from 2005 - 2021
This document summarizes and includes language from legislation pertaining to the Money Follows the Person Demonstration.
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ACL: Advancing the NWD System through Money Follows the Person Demonstration Partnership
This document describes the benefits that can be achieved through partnerships between the NWD System and the Money Follows the Person Demonstration, as well as strategies for developing…
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Medicaid: Money Follows the Person Resources Page
Description: This page on the Medicaid.gov website provides information on the Money Follows the Person program, including program goals, grantee information, and evaluation information and reports.…
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ADRC TA Exchange: Building Collaborative Partnerships between the Money Follows the Person Rebalancing Demonstration and ADRCs
Description: This toolkit provides partnership support to both Aging and Disability Resource Centers and Money Follows the Person Rebalancing Demonstration programs and contains useful information…
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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,…
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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…
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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),…
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ACL: Federal Hospital Care Transitions Resources and the Aging and Disability Network
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.…
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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…
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Care Transitions March Peer Hour - Role of CBOs in Addressing SDoH Recording
Description: The following is a recording link for the Care Transitions March Peer Hour - Role of CBOs in Addressing SDoH call held on March 31, 2021. *If you would like the transcript for this call,…
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Care Transitions December Peer Hour - Michigan Hospital Transitions FAQ
Description: This FAQ document lists the questions posed during the Care Transitions December Peer Hour - Michigan Hospital Transitions held on December 1, 2020 and their corresponding answers.
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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…
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Iowa: Return to Community Pilot Initiative Manual
Description: The Iowa Return to Community (IRTC) Program is a collaborative effort with a variety of partners including hospitals, long-term care facilities, Area Agencies on Aging (AAA),…