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Care Transitions: Resources for the Aging Network

This page provides a consolidated directory of key resources for the Aging Network implementing care transition programs. This page links to relevant areas of the AoA website as well as to outside resources of key partners to AoA, such as Quality Improvement Organizations (QIOs), Center for Medicare & Medicaid Services (CMS), and the Agency for Healthcare and Quality (AHRQ).

Care transitions programs aim to improve coordination between hospitals, physicians and community service providers and help reduce health care costs through prevented readmissions while supporting individuals and caregivers who experience a transition in their care setting.

The Aging Network is critically important to improving transitions across care settings. By providing access to Older Americans Act (OAA) core services, decision support and options counseling, and care coordination across care settings, the Aging Network can help maximize independence for individuals at-risk of multiple readmissions and their caregivers.

Resources for Individuals, Families, Caregivers

If you are an individual, caregiver, or family member seeking additional information on planning for hospital discharge or preventing readmission, below are links to helpful information.

AoA's Care Transitions Resources for Individuals and Families Page

AoA's General Information for Consumers Page
For more localized information and assistance, including the Eldercare Locator. These resources are not limited exclusively to care transitions.

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Resources for the Aging Network

AoA Webinar Series: Care Transitions

This series of webinars focuses on preparing the Aging Network to participate in the Community-based Care Transition Program demonstration (Sec. 3026 of the Affordable Care Act) and other related care transitions programs. The webinar presentations offer a unique opportunity to hear firsthand from those involved across different care transitions programs from all over the aging network. Many webinars highlight success stories, challenges and potential solutions from those who have already successfully implemented programs.

AoA Care Transitions Toolkit

Developed for States, Area Agencies on Aging, Aging and Disability Resource Centers, Tribal Organizations, and other local service providers within the National Aging Network, the Administration on Aging Care Transitions Toolkit is targeted to organizations that are interested in learning more about how to prepare their organization for a role in care transitions programs. The tools and resources here can assist in formalizing efforts for future funding and program opportunities.

This toolkit includes lessons learned from States that received funding from the Aging and Disability Resource Center (ADRC) Program, ADRC Evidence-Based Care Transitions Program, Person-Centered Hospital Discharge Model, Community Living Program (CLP), and the Veteran Directed Home and Community Based Services (VD-HCBS) Program.

Download entire toolkit and attachments (ZIP 0.5 MB)

Aging and Disability Resource Centers Evidence-Based Care Transitions

The Aging and Disability Resource Centers (ADRC) Evidence Based Care Transitions program supports state efforts to significantly strengthen the role of ADRCs in implementing evidence-based care transition models that meaningfully engage older adults and individuals with disabilities (and their informal caregivers). This grant opportunity is designed to promote the further development and enhancement of ADRC participation in evidence-based care transition models. Grantees have developed strategies to maintain fidelity to evidence based models while augmenting care transition services to include greater access to long term services and support in the community post-discharge.

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Federal Programs Focused on Care Transitions

Partnership for Patients: Better Care, Lower Costs

A wide variety of public and private partners work to achieve the two core goals of Partnership for Patients — keeping patients from getting injured or sicker in the health care system and helping patients heal without complication by improving transitions from acute-care hospitals to other care settings.

Community-Based Care Transitions Program
Funding under Partnership for Patients is available through the Community-Based Care Transitions Program (CCTP). The goals of the CCTP are: to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

Community-Based Care Transition Program Participant Summaries

Money Follows the Person

The “Money Follows the Person” Rebalancing Demonstration Program (MFP) helps States rebalance their long-term care systems to transition people with Medicaid from institutions to the community. The program helps to ensure safe and successful care transitions by facilitating access to home and community-based services and ensuring the quality of such services.

Money Follows the Person Technical Assistance

Medicaid Health Homes

Health homes are a conduit to lowering health care costs, increasing quality, reducing health disparities, achieving better outcomes, lowering utilization rates, improving compliance with recommended care, and coordinating a spectrum of medical and social services required by the individual across the lifespan.

Medicaid Health Homes Technical Assistance

Accountable Care Organizations (ACOs)

ACOs give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.

Beacon Community Program

The goal of the Beacon Community Program is to show how health IT tools and resources can contribute to communities’ efforts to make breakthrough advancements in health care quality, safety, efficiency, and in public health at the community level and to demonstrate that these gains are sustainable and replicable.

Beacon Community Program Technical Assistance

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

Through this initiative, CMS will partner with eligible, independent, non-nursing facility organizations (referred to as "enhanced care & coordination providers") to implement evidence-based interventions that reduce avoidable hospitalizations. Nursing facility residents are especially vulnerable to the risks that accompany hospital stays and transitions between nursing facilities and hospitals. Eligible organizations can include Area Agencies on Aging, Aging and Disability Resource Centers, Centers for Independent Living, care management organizations, and other entities.

Quality Improvement Organizations (QIO)

QIOs work with patients, providers and practitioners across organizational, cultural and geographic boundaries to spread rapid, large-scale change. The work that QIOs perform spans every setting in which health care is delivered, even the critical transitions between those settings. The Program focuses on three aims: better patient care, better individual and population health, and low health care costs through improvement. In order to accomplish these goals, QIOs collaborate with beneficiaries, patient advocacy groups, patient safety organizations, and local communities, among others.

The National Coordinating Center (NCC) for the Integrating Care for Populations and Communities Aim (ICPCA) Care Transitions Toolkit
The NCC assists Medicare Quality Improvement Organizations (QIOs) to promote seamless transitions between health care settings and provides resources for communities who are developing local care transitions programs.

Find a Local Quality Improvement Organization (QIO)

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More Resources on Care Transitions

AoA’s Health Reform Page

AHRQ Care Coordination Measures Atlas
AHRQ’s new Care Coordination Measures Atlas lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination.

Better Outcomes for Older adults through Safe Transitions (BOOST)

Bridge program

Care Transitions InterventionSM

Guided Care®

Transitional Care Model

AHRQ Health Care Innovations Exchange
The Innovations Exchange helps you solve problems, improve health care quality, and reduce disparities.

CMS Chronic Conditions Among Medicare Beneficiaries Chart Book

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