In most care transition programs, participants are first engaged while in an acute care settings and then followed intensively after discharge to the community. The basic goals of a care transitions program are to:
- Ensure that patients/residents and their caregivers understand how to adhere to post-discharge instructions for medication and self-care;
- Recognize symptoms that signify potential complications requiring immediate attention; and
- Make and keep follow-up appointments with their primary care physicians.
The Administration on Community Living (including Administration on Aging as of April 2012) ADRC Evidence Based Care Transitions program promotes ADRC participation in evidence based care transitions models through:
- Increasing the capacity of ADRCs’ current involvement in evidence-based care transition initiatives through expansion;
- Strengthening existing transitions programs and leverage the assets of the ADRCs;
- Informing ACL/CMS, other Federal agencies and Congress on national policy related to care transitions, hospital discharge planning, person-centered planning, and mechanisms to reduce unnecessary hospital re-admissions.
In 2010, sixteen states implementing evidence based care transition models were issued awards by ACL: California, Colorado, Connecticut, Florida, Illinois, Indiana, Maine, Maryland, Massachusetts, New Hampshire, New York, Pennsylvania, Rhode Island, Tennessee, Texas and Washington. These were awarded following an ACL program announcement in 2009, which expanded ADRC's emphasis on reaching to people during transitions in care by:
- Naming "person-centered hospital discharge planning" as a key operational component of an ADRC; and
- Describing situations where ADRCs can either direct transitional care interventions, or support those that do
CMS has also identified ADRCs as "key facilitators in care coordination" to increase opportunities for people who are at-risk of institutionalization to live in the community following a hospitalization. CMS has awarded Real Choice Systems Change (RCSC) Grants for "Person-Centered Hospital Discharge Planning Models" to states including Alaska, California, Hawaii, Kansas, Maryland, Missouri, North Carolina, Oregon, and South Carolina.
Quarterly ADRC Care Transitions Quarterly Work Group Call
This Care Transitions Workgroup call is open to all who are interested in care transitions.
Past Work Group Calls
Option D Grantees (grantee access only)
More information about Care Transitions