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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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AoA: Care Transitions Toolkit - Chapter Six: Implementation and Day-to-Day Operations
This chapter provides information on cross-training partners; identifying appropriate candidates for your program; providing care transitions support to consumers and caregivers;…
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AoA: Care Transitions Toolkit - Chapter Five: Building Organizational Capacity
This chapter provides information on building internal infrastructure; staffing models and workflow; ensuring person-centeredness; costs and billing procedures;…
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AoA: Care Transitions Toolkit - Chapter Three: Developing Effective Partnerships
This chapter provides information identifying potential CT partners; cross cultural strategies for strengthening partnerships; making the business case;…
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AoA: Care Transitions Toolkit - Chapter Two: Taking Time to Plan
This chapter provides information on conducting a root cause analysis, assessing your organization; program policies, and procedures, and day-to-day operations; service management;…
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AoA: Care Transitions Toolkit - Chapter One: Getting Started
This chapter provides a definition and overview of care transitions, evidence-based models and how the aging network supports care transitions. Since the original care transitions toolkit…
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AoA: Care Transitions Toolkit - Overview
The Administration on Aging (AoA) developed a toolkit in 2012 to provide guidance to the aging network on how to begin or establish care transitions programs.…
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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),…
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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.…
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Care Transitions Peer Hour - Alabama's Partnerships Recording
Description: The following is a recording link for the Care Transitions Peer Hour - Alabama's Partnerships call held on October 22, 2020. *If you would like the transcript for this call,…
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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…
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Care Transitions December Peer Hour - Michigan Hospital Transitions Slides
PowerPoint slides for the Care Transitions December Peer Hour - Michigan Hospital Transitions call.
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Care Transitions Peer Hour - Institutional Transitions Recording
Description: The following is a recording of the Care Transitions Peer Hour - Institutional Transitions call held on September 15, 2020. *If you would like the transcript for this call,…
NWD Technical Assistance Community
A collaboration space for No Wrong Door (NWD) community and partners