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SARCOA Hospital to Home Slides
Description: This PowerPoint slide deck provides a brief overview of SARCOA Area Agency on Aging's Hospital to Home program.
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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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Hospital Discharge Planning Worksheet
Description: This worksheet includes a list of items that must be assessed during the on-site survey, in order to determine compliance with the Discharge Planning Condition of Participation.…
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Care Transitions - Alabama's Partnerships Slides
PowerPoint slides for the Care Transitions Peer Hour - Alabama's Partnerships call.
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CMS Final Rule on Discharge Planning Requirements
Description: This final rule empowers patients to be active participants in the discharge planning process and complements efforts around interoperability that focus on the seamless exchange of…
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Care Transitions Peer Hour - Institutional Transitions FAQ
Description: This FAQ document lists the questions posed during the Care Transitions Peer Hour - Institutional Transitions held on September 15, 2020 and their corresponding answers.
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Care Transitions Peer Hour - AL's Partnerships FAQ
Description: This FAQ document lists the questions posed during the Care Transitions Peer Hour - Alabama's Partnerships held on October 22, 2020 and their corresponding answers.
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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: 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 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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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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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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New Opportunities for Serving Complex Care Populations in Medicare Advantage
Description: This slide deck by the SCAN Foundation details the findings of an analysis using 2015 Medicare Current Beneficiary Survey (MCBS). This analysis includes Medicare beneficiaries of all…
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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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Discharge Planning and Care Coordination during the COVID-19 Pandemic
Description: This tool is designed to support nurses, social workers, case managers, and others conducting effective discharge planning and care coordination for adults with disabilities who…
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CMS Chronic Conditions Chart Book
Description: This slide deck contains select graphical figures from the CMS Chronic Conditions Chartbook.
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CMS Announces Relief for Clinicians, Providers, Hospitals and Facilities Participating in Quality Reporting Programs in Response to COVID-19
Description: This news article details an announcement put out by the Centers for Medicare & Medicaid Services (CMS) regarding unprecedented relief for the clinicians, providers,…
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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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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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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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SCAN Foundation Data Brief: Medicare Spending by Functional Impairment and Chronic Conditions
Description: This analysis is based on the 2006 Medicare Current Beneficiary Survey (MCBS) Cost and Use file, an annual, longitudinal survey of a representative sample of all Medicare enrollees.…
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Discharge Planning and Care Coordination during the COVID-19 Pandemic
Description: This tool is designed to support nurses, social workers, case managers, and others conducting effective discharge planning and care coordination for adults with disabilities who…
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Discharge Planning CBO - Section Final Rule
Description: This final rule empowers patients to be active participants in the discharge planning process and complements efforts around interoperability that focus on the seamless exchange of…