-
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…
-
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…
-
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…
-
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),…
-
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.…
-
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…
-
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;…
-
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.…
-
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…
-
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…
-
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,…
-
SARCOA Hospital to Home Program Marketing Video
Description: This marketing video provides information on SARCOA's Hospital to Home program aimed at assisting Medicaid beneficiaries return to their homes after a hospitalization.
-
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.
-
Care Transitions Peer Hour - Hospital to Home Slides
PowerPoint slides for the Care Transitions Peer Hour - Hospital to Home call.
-
CMS Acute Hospital Care At Home
Description: The Centers for Medicare & Medicaid Services (CMS) outlined comprehensive steps to increase the capacity of the American health care system to provide care to patients outside a…
-
Care Transitions Peer Hour - Institutional Transitions Slides
PowerPoint slides for the Care Transitions - Institutional Transitions call.
-
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…
-
Care Transitions December Peer Hour - Michigan Hospital Transitions Recording
Description: The following is a recording link for the Care Transitions December Peer Hour - Michigan Hospital Transitions call held on December 1, 2020.…
-
Virginia: Older Adults & Social Isolation: The Other Epidemic
Description: The Virginia NWD System developed this fact sheet on social isolation to share with hospitals to facilitate care transitions partnerships.…
-
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.…
-
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…
-
Care Transitions November Special Session Slides
PowerPoint slides for the Care Transitions November Special Session call.
-
Adapting Care Transitions Amidst Pandemic - Council on Aging of Southwestern Ohio
Description: This article presents an overview of Fast Track Home, the care transitions program of the Council on Aging of Southwestern Ohio (COA). Click here to access the resource: https://www.n4a.…
-
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 ·…