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Care Transitions: Building Partnerships to Support Health Related Social Needs
The HHS Administration for Community Living (ACL) is inviting hospitals, health systems, Accountable Care Organizations (ACOs) and community-based organizations (CBOs) to a special series of learning…
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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. Click here for more information on sustaining a NWD…
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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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AARP: LTSS Scorecard Website
Description: The Long-Term Services and Supports (LTSS) State Scorecard—a compilation of state data and analysis—showcases measures of state performance for creating a high-quality system of care in…
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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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ACL: Episode 1: Supporting COVID-19 Challenges Through Care Transitions Partnerships
Description: Join Tim McNeill as he discusses best practices associated with care transitions amid the COVID-19 pandemic, where he will facilitate and provide guidance on how to support your local…
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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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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…
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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 Peer Hour - Hospital to Home Recording
Description: The following is a recording of the Care Transitions Peer Hour - Hospital to Home call held on September 8, 2020. *If you would like the transcript for this call,…
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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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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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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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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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Indiana NWD Business Case: Person-Centered Counseling and Care Transition Intervention
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 long term…
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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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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…
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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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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,…
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Promoting Home and Community-based Services in Washington
Key Partners: ADRCs (CLCs), hospitals, IT vendor, Rush University CHASI (Bridge Care Transitions Model) Washington state continually innovates to promote access to home and community-based services…
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NLC Network Expansion Track Meeting 1/12/23
The second Network Expansion Track meeting focused on health and housing financing strategies. Please see meeting slides attached. Resources shared during the meeting:…
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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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Care Transitions Peer Hour - Hospital to Home FAQ
Description: This FAQ document lists the questions posed during the Care Transitions Peer Hour - Hospital to Home held on September 8, 2020 and their corresponding answers.