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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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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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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.
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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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Alaska: ADRC ATLA Program Overview
Description: This document provides a background on Assistive Technology of Alaska (ATLA), an overview of their AT program, services and training topics offered by ATLA to enhance the professional…
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Alaska: ADRC Staff Workflow for Identifying and Generating AT Referrals
Description: This flowchart breaks down the workflow Alaska ADRC staff follow for identifying and generating assistive technology (AT) referrals. The flowchart is broken down into three main…
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Virginia: 3 Ways to Support Older Adults
Description: Virginia created a flyer advertising some ways to support older adults and combat social isolation during the pandemic. Click here to access the resource: https://sharepoint.wwrc.…
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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.…
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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 - Institutional Transitions Slides
PowerPoint slides for the Care Transitions - Institutional Transitions call.
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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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CMS Chronic Conditions Chart Book
Description: This slide deck contains select graphical figures from the CMS Chronic Conditions Chartbook.
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Medicare Advantage Demographics Report, 2015
Description: This issue brief presents key findings on Medicare Advantage, a program that provides affordable, high-quality coverage to all seniors. New data from the Medicare Current Beneficiary…
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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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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…
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COVID-19 Long-Term Care Facility Guidance
Description: The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are issuing new recommendations to State and local governments and long-term…
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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.…
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Care Transitions Peer Hour - Hospital to Home Slides
PowerPoint slides for the Care Transitions Peer Hour - Hospital to Home call.
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ACL Seeks Solutions to Match People Who Are Socially Isolated with Available Social Engagement Programs and Technology Solutions
Social isolation has enormous health consequences – it has been found to be as harmful to a person’s health as smoking 15 cigarettes a day. People who are socially isolated or lonely face higher…
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ACL Launches Health IT Prize Competition
Partnerships between health care and community-based social services organizations have been shown to improve health outcomes and lower costs. ACL launched a Challenge Competition to spur…
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ACL’s COVID-19 Resources: What’s New
ACL has uploaded new resources to their COVID-19 resource page. Click https://acl.gov/news-and-events/announcements/acls-covid-19-resources-whats-new-5 for more information.
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Contact Us
To contact the ACL/Technical Assistance team, please email: NoWrongDoor@acl.hhs.gov