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The Aging Network and Care Transitions: Preparing your Organization Toolkit

Toolkit Overview

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. Whether your organization has historically developed partnerships with health care providers or programs that span the continuum of care such as Community Living, Money Follows the Person, Aging and Disability Resource Centers, or others, the tools and resources here can assist in formalizing your 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.

The Aging Network and Care Transitions

The Aging Network is critically important to improving transitions across care settings. Many people served by the Aging Network are considered high-risk for multiple hospital readmissions and the accompanying health complications. Providing access to Older Americans Act (OAA) core services, decision support, and care coordination across the continuum of care are all central to the mission of the Aging Network to maximize independence for at-risk individuals. As the national landscape of long-term services and supports transforms, the Aging Network can capitalize on existing infrastructure to mobilize its efforts and embrace the business, organizational, and cultural changes that will bridge the gaps between medical and long-term services and supports.

Toolkit Contents

Toolkit Introduction

Chapter One: Getting Started

Chapter Two: Taking Time to Plan

Chapter Three: Developing Effective Partnerships with Health Care Providers

Chapter Four: Measuring for Success

Chapter Five: Building Organizational Capacity

Chapter Six: Implementation and Day-to-Day Operations

Download entire toolkit and attachments (ZIP 0.5 MB)

Questions or comments about the toolkit? Email