Care Transitions Resources
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2012 ADRC Joint Program Funding Announcement Press Release 
Source: ACLThis is a funding opportunity from the Administation for Community Living (ACL), Centers for Medicare and Medicaid Services (CMS), and the Veteran's Health Administration (VHA), number HHS-2012-ACL-RO-1210. This opportunity is for states to significantly strengthen and expand their long term services and supports Options Counseling (LTSS OC) programs. Application deadline is July 25, 2012.
(Word) (PDF) Associated Date: May 2012 The Aging Network and Care Transitions: Preparing your Organization Toolkit
Source: AoA
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.
(External Link) • File type: web
Associated Date: August 08, 2011
Care Transitions QIOSC Toolkit
Source: Quality Improvement Organization Support Center (QIOSC)
Care Transitions QIOSC Toolkit provides numerous resources that can help community-based organizations, such as ADRCs, and hospitals develop partnerships, conduct root cause analyses, identify interventions, and measure their success.
(External Link)
(PDF)
Associated Date: April 2011
AoA Webinar: Partnership for Patients: The Community-based Care Transition Program
Source: AoA
These are the slides and transcript from the April 20, 2011 AoA webinar: Partnership for Patients: The Community-based Care Transition Program.
(PDF) Caption: Slides
(PDF) Caption: Transcript
Associated Date: April 20, 2011
Solicitation for Applications Community-based Care Transitions Program
Source: Centers for Medicare and Medicaid
From CMS this Solicitation for Applications outlines the requirements for applicants applying for Community Based Care Transitions grants.
(PDF)
Updated June 6, 2011
2010 Program and Funding Announcement - Implementing the Affordable Care Act: Making it Easier for Individuals to Navigate their Health and Long-Term Care through Person-Centered Systems of Information, Counseling and Access
Source: Administration on Aging
The Administration on Aging and the Centers for Medicare & Medicaid Services will jointly award up to $60 million in formula and competitive grants through this Program Announcement. There are four distinct funding opportunities being made available under this Announcement. The first opportunity makes formula funds available to States, Area Agencies on Aging (AAAs), State Health Insurance Assistance Programs (SHIPs) and Aging and Disability Resource Centers (ADRCs) to provide outreach and assistance to Medicare beneficiaries on their Medicare benefits including prevention. The Announcement also includes two competitive funding opportunities that are available to all existing ADRC grantees - one to strengthen ADRC Options Counseling and Assistance Programs, the other to strengthen the role of ADRCs in Evidence-Based Care Transition Models that integrate the medical and social service systems to help older individuals and those with disabilities remain in their own homes and communities after a hospital, rehabilitation or skilled nursing facility visit. Finally, for existing Money Follows the Person state grantees, there is an opportunity to compete for supplemental administrative funds that can be used to strengthen the capacity existing ADRCs to participate in Nursing Home Transitions and Diversions Programs.
(Word)
(Word) Caption: DHHS Press Release
(PDF)
(PDF) Caption: DHHS Press Release
Added June 3, 2010
TAE Training Handouts: ADRC Overview Handouts
Source: Technical Assistance Exchange
This series of handouts was developed by the TAE to be distributed in conjunction with ADRC training sessions. Topics covered are an ADRC Overview, Options Counseling, Sustainability, Partnership, Social Marketing, Care Transitions, and Serving Private Pay Consumers. Grantees may find them useful for quick reference.
(PDF) Caption: ADRC Overview
(PDF) Caption: Options Counseling
(PDF) Caption: Partnership
(PDF) Caption: Private Pay
(PDF) Caption: Social Marketing
(PDF) Caption: Care Transitions
(PDF) Caption: Sustainability
(Word) Caption: ADRC Overview
(Word) Caption: Options Counseling
(Word) Caption: Partnership
(Word) Caption: Private Pay
(Word) Caption: Social Marketing
(Word) Caption: Care Transitions
(Word) Caption: Sustainability
Associated Date: May 2010
WA AAA Care Transitions Toolkit
Source: Washington
The Aging and Disability Resource Center (ADRC) Care Transitions Intervention Tool Kit was developed to provide AAAs in Washington state with the tools to support Care Transitions Program implementation in their communities. It includes a description of the model, and an overview of the organizational preparation required prior to scheduling training through the Care Transition Program. This Tool Kit is an interactive PDF document with web links for all of the tools.
(External Link) • File type: pdf
(PDF)
Associated Date: April 2013
Connecticut Option D Profile (no available resources yet)
Source: TAE
This is Connecticut's profile for the Option D Care Transitions grant.
Associated Date: February 13, 2013
Family Caregiving and Transitional Care: A Critical Review
Source: FCA
The Family Caregiver Alliance released this report on the role of caregiving families as patients transition from one healthcare setting to another. It notes that family caregivers are rarely actively included in care planning and receive inadequate training. This frequently leads to preventable negative outcomes for patients.
(External Link) • File type: pdf
(PDF)
Associated Date: December 2012
Care Transitions Work Group Slides - December 10, 2012
Source: 0
This is the PowerPoint presentation for the December 10, 2012 ADRC Quarterly Care Transitions Work Group Call. Presenters include Caroline Ryan from ACL and the Option D grantee team from California.
(Powerpoint)
(PDF)
Associated Date: December 10, 2012
Care Transitions Work Group Call September 24, 2012 Presentation
Source: TAE
This is the Care Transitions Work Group Call slide deck presentation from September 24, 2012.
(Powerpoint)
(PDF)
Added September 24, 2012
Overview of Preparing Community-Based Organizations for Successful Health Care Partnerships
Source: The Scan Foundation
The Scan Foundation developed this background brief on how best to build partnerships between community-based long-term services and healthcare systems to improve care transitions and coordination. It focuses on specific opportunities for these partnerships in California.
(External Link) • File type: web
(PDF)
Associated Date: August 2012
June 11, 2012 - Care Transitions Work Group Call Slides
Source: ACL
These are the slides for the June 11, 2012 ADRC Care Transitions Work Group Call.
(Powerpoint)
(PDF)
Associated Date: June 11, 2012
Section Q MFP, ADRC, & VA Roles, POC lists & Web Resources List
Source: Veterans Administration
Document highlighting MDS 3.0 Section Q Roles and Resources within state Money Follows the Person Demonstrations Programs, Local Contact Agencies, Veterans Geriatrics and Extended Care Services (GEC) and State Veterans Homes (SVH).
(PDF)
Associated Date: March 2012
Section Q Case Studies
Source: Dann Milne
Case studies used during the MDS Section Q half day conference as a group exercise illustrating the coding of Section Q and person-centered care planning resources available to nursing facilities.
(PDF) Caption: Section Q Case Studies
(PDF) Caption: Section Q Case Studies with Answers
Associated Date: March 2012
Ohio Medicaid & State Veterans Home Partnership Talking Points
Source: Ohio
Talking points illustrating the developing partnership between Ohio Medicaid and the Ohio State Veterans Home presented by Terry Moore.
(PDF)
Associated Date: March 2012
Minnesota VD-HCBS Orientation Pamphlet
Source: Southwestern Center for Independent Living
Veteran’s Directed Home and Community Based Services (VD-HCBS) educational and informational brochure prepared by the Minnesota Southwestern Center for Independent Living (SWCIL) providing veterans with information and options available through VD-HCBS.
(PDF)
Associated Date: March 2012
March 2012 Section Q St Louis Meeting Agenda
Source: CMS
March 2012 Section Q half day conference agenda highlighting presentations on Section Q changes, State Veterans Home and VA Transition Referral Processes, Aging and Disability Resource Centers, and Ombudsmen Role in Transition.
(PDF)
Associated Date: March 2012
Minnesota Veterans Directed Home and Community-Based Services PowerPoint
Source: Southwest Center for Independent Living
Slide deck reflecting the importance of rural partnerships with Veteran Directed Home and Community Based Services including personal stories from veterans in Texas and Minnesota. Presented by Lori Gerhard for Steve Thovson.
(PDF)
Associated Date: March 2012
Veterans Administration Eligibility & Services Overview PowerPoint
Source: Veterans Administration
Slide deck presenting the Veterans Administration philosophy for long term services and supports with a focus on the growth in home and community based services and critical partnerships with the Administration on Aging and the Centers for Medicare and Medicaid Services. Presented by Dan Schoeps and Patrick O’Keefe.
(PDF)
Associated Date: March 2012
MDS 3.0 Section Q Ombudsman Roles PowerPoint
Source: AoA
Slide deck reflecting the historical and emerging role of ombudsmen in nursing facility transition and community living options. Presented by Becky Kurtz.
(PDF)
Associated Date: March 2012
Section Q ADRC Roles and Transitions Roadmap PowerPoint
Source: TAE
Slide deck illustrating the role of aging and disability resource centers in nursing facility transition efforts including a step by step transition model and innovative practices in CT, MD, MO, OH, and TX.
(PDF)
Associated Date: March 2012
Section Q April 2012 Changes to MDS 3.0 PowerPoint
Source: Dann Milne
Slide deck presented by Dann Milne on Minimum Data Set (MDS) 3.0 Section Q changes, the purpose for the changes, results from the input process and pilot test, side by side comparison of current versus new changes effective April 1, 2012, highlights of the applicable sections of the RAI User’s Manual as well as expected impacts.
(PDF)
Associated Date: March 2012
Right Place Right Time Right Care
Source: Scripps Gerontology Center
This is the report from the evaluation of Ohio's Nursing Home diversion and transition project done by Scripps Gerontology Center.
(PDF)
Associated Date: June 2011
OHT ODA Outcomes Chart
Source: Ohio
A flow chart showing the relationship between the state Office of Health Transformation goals in Ohio and the outcomes for "aging" waiver programs the AAAs are working towards.
(PDF)
Associated Date: October 2011
COA CT evaluation
Source: Council on Aging of Southwestern Ohio
A Powerpoint presentation on the evaluation done by the Council on Aging of Southwestern Ohio on its Care Transitions Project.
(Powerpoint)
(PDF)
Associated Date: October 2011
CO_CTI_Motivational_Flier_for_patients
Source: Colorado
This flier is used in Colorado to encourage patients to engage in the Care Transitions program.
(PDF)
Associated Date: October 2011
CTI Activation Assessment
Source: New Hampshire
New Hampshire created this Care Transitions Intervention assessment that includes a "Patient Activation Assessment" and Medication Discrepancy Tool.
(Word)
(PDF)
Associated Date: October 2011
Care Transitions Work Group Slides 01-23-12
Source: TAE
These are the slides from the January 23, 2012 Care Transitions Work group call.
(Internal Link) Caption: PDF • File type: pdf
(Internal Link) Caption: Powerpoint • File type: ppt
Associated Date: January 23, 2012
Care Transitions Work Group Call, December 12, 2011
Source: AoA
These are the slides from the December 12, 2011 Care Transitions Work Group Call
(PDF)
Added December 14, 2011
First Seven CCTP Awarded CBOs/Sites
Source: CMS
The first seven CCTP awards have been announced. These are brief synopses of each awardee.
(PDF) Caption: Akron / Canton AAA
(PDF) Caption: Atlanta Regional Commission
(PDF) Caption: Chicago
(PDF) Caption: Maricop County Arizona
(PDF) Caption: Merrimack Valley
(PDF) Caption: Southern Maine AAA
(PDF) Caption: SW Ohio
Associated Date: November 29, 2011
Washington - Care Transitions Toolkit Cover (Table of Contents)
Source: Washington
This is the table of contents for Washington's care transitions toolkit.
(PDF)
Associated Date: December 12, 2011
Colorado Care Transitions Flyer for Consumers
Source: Colorado
The Colorado ARCH (ADRC) developed this flyer for consumers explaining the Evidence-Based Care Transitions Program.
(Word)
(PDF)
Associated Date: October 2011
Care Transitions Work Group Call, September 22 Call Notes
Source: TAE
These are the notes from the September 22, 2011 Care Transitions Work Group Call
(Word)
(PDF)
Added November 3, 2011
New York's Care Transitions Flow Chart
Source: New York
This is the New York State CTI-Plus Program Pathway / flow chart for their care transitions program.
(PDF)
Associated Date: September 22, 2011
AHRQ Initiative: "Questions are the Answer"
Source: AHRQ
The U.S. Department of Health and Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ) launched an initiative with the Ad Council to encourage clinicians and patients to engage in effective two-way communication to ensure safer care and better health outcomes. For nearly a decade, AHRQ has encouraged patients to be more involved in their health care, and this new initiative builds on previous public education campaigns AHRQ has conducted under contract with the Ad Council around the theme "Questions are the Answer." The Web site features new resources to help patients be prepared before, during and after their medical appointments. The resources including: an interactive "Question Builder" tool that enables patients to create, prioritize and print a personalized list of questions based on their health condition; a brochure, titled "Be More Involved in Your Health Care: Tips for Patients," that offers helpful suggestions to follow before, during and after a medical visit; and notepads designed for use in medical offices to help patients prioritize the top three questions they wish to address during their appointment.
(External Link)
Associated Date: September 21, 2011
Care Transitions Work Group Call Notes - June 16, 2011
Source: TAE
These are the notes from the June 16, 2011 Care Transitions Work Group Call.
(Word)
(PDF)
Associated Date: June 16, 2011
Care Transitions Work Group September 22, 2011 PowerPoint Slides
Source: AoA
These are Caroline Ryan's PowerPoint slides for the September 22, 2011 Care Transitions Work Group Call.
(Powerpoint)
(PDF)
Associated Date: September 22, 2011
Washington State: Hospitals 101
Source: Washington
A guide created by Washington state to help individuals understand important things to know about the process and how to best prepare themselves.
(Powerpoint)
(PDF)
Associated Date: September 2011
Washington State ADRC Care Transitions Intervention Model
Source: Washington
A model for Care Transitions intervention from Washington state
(Powerpoint)
(PDF)
Associated Date: September 2011
WA Option D Care Transitions Evaluation Plan
Source: Washington
Washington state's Option D Evidence Based Care Transition Grantees Evaluation Plan
The model below depicts the interventions, and the intervening factors (or control variables) and outcomes that will be measured as part of the evaluation of Washington State’s Care Transitions Project, ADRC Care Transitions Coaching Program.
(Word)
(Word) Caption: text version
(PDF)
Associated Date: September 2011
CT News article: "Coaching patients to keep them from returning to the hospital"
Source: Connecticut Mirror
Nice highlights of the ADRC efforts and Care Transitions Intervention (CTI) activities in this Connecticut Mirror news article, "Coaching patients to keep them from returning to the hospital."
(External Link)
Associated Date: August 31, 2001
New Hampshire - Care Transitions Conference
Source: New Hampshire
A 2-day conference was organized by the New Hampshire Institute for Health Policy and Practice and the Northern New England Geriatric Education Center with the goal of educating and fostering collaboration among NH communities. Day 1 of the conference featured renowned experts in care transitions models, such as Dr. Eric Coleman & Dr. Mary Naylor. Day 2 was comprised of seven different panelists presenting on various care transitions and care coordination models being implemented throughout NH.
On the Care Transitions Conference page, there is a conference summary outlining what was achieved through the 2-day event, conference materials and PowerPoint presentations, and a summary of the pre-conference inventory taken of current care transitions and care coordination activities being implemented throughout NH.
(External Link)
Associated Date: June 15, 2011
Maine's Care Transitions Intevention (CTI) Flow Chart
Source: Maine
This flow chart depicts the process by which the CTI project in Maine operates.
(Word)
(PDF)
Added August 25, 2011
Leveraging ADRCs to Improve Transitional Care
Source: Georgia
The Medicare Quality Improvement Organization for Georgia (GMCF), prepared this document on leveraging ADRCs to improve transitional care. The purpose of the document is to help improve connections between the acute care hospital environment and community resource agencies as a method to improve transitional care and reduce the risk of avoidable rehospitalization.
(PDF)
Associated Date: April 2011
Tech4Impact Diffusion Grants Program
Source: Center for Technology and Aging
This document includes abstracts for the Tech4Impact Diffusion Grants Program awardees, summary of the programs
(PDF)
Associated Date: January 2011
AHRQ Website Helps Hispanics Communicate More with Their Doctors
Source: AHRQ
The Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) recently launched, Conozca las preguntas, a new Spanish-language website that encourages Hispanics to get more involved in their health care and provides tips to improve patient-provider communication. AHRQ data show that the proportion of Hispanics who report having poor communication with their health providers widening. The data also show that Hispanics are significantly less likely than non-Hispanic whites to see a doctor
at least once a year even when they have health insurance, and they also are much less likely to get important screening tests for diseases, such as diabetes and cancer. The website also features downloadable public service announcements (PSAs) from AHRQ’s nationwide campaign with the Ad Council.
(External Link) • File type: web
Associated Date: July 05, 2011
Colorado's Care Transitions Flow Chart
Source: Colorado
Colorado developed a flow chart on their program model for Care Transitions.
(Word)
Associated Date: August 25, 2011
Navigating Across Care Settings Discharge Materials
Source: Massachusetts
Massachusetts designed these materials for patients and families that may be interested in participating in the Navigating Across Care Settings discharge program. The materials include a program brochure, a letter to patients and a letter to families as well as a description of participant inclusion and exclusion critieria.
(Word) Caption: Patient Letter in Hospital
(Word) Caption: Inclusion Exclusion Criteria
(Word) Caption: Family Letter in Hospital
(PDF) Caption: Family Letter in Hospital
(PDF) Caption: Patient Letter in Hospital
(PDF) Caption: Brochure
(PDF) Caption: Inclusion Exclusion Criteria
Associated Date: April 2011
Connecticut Care Transitions Flowchart
Source: Connecticut
The North Center Connecticut ADRC created this flow chart for its Care Transitions program.
(PDF)
Associated Date: February 2011
Hospital to Home: Enhancing Safe Transitions through Innovative Community Partnerships in Maine
Source: Maine
This presentation was given by Peggy Haynes of MaineHealth and Larry Gross of the Southern Maine AAA at the 2011 n4a conference. This presentation provides an overview of the opportunities to link ADRCs with health system interventions and cross-training opportunities between healthcare care management programs and ADRCs.
(PDF)
Associated Date: July 18, 2011
Budget Worksheets to Develop Unit Rates for Care Transitions Program Costs
Source: Ohio
This set of budget worksheets (Tabs A, B and C) comes from the Council on Aging of Southwestern Ohio. They can be used to assist in developing a unit rate for various program costs for care transitions.
(Excel)
Associated Date: July 2011
New Hampshire Care Transitions Conference Materials
Source: New Hampshire
New Hampshire Care Transitions Conference
This was a 2-day conference organized by the New Hampshire Institute for Health Policy and Practice and the Northern New England Geriatric Education Center with the goal of educating and fostering collaboration among NH communities. Day 1 of the 2 day conference featured renowned experts in care transitions models, such as Dr. Eric Coleman & Dr. Mary Naylor. Day 2 was comprised of seven different panelists presenting on various care transitions and care coordination models being implemented throughout NH.
(PDF) Caption: Brochure
(PDF) Caption: Day 2 Detailed Insert
Associated Date: April 26, 2011
Slides and Recording of Reducing Readmissions Through Care Transitions Webinar
Source: National Quality Forum
The second Partnership for Patients webinar, which took place on July 6, 2011, discussed the goal of decreasing complications during transitions between care settings to reduce hospital readmissions by 20%. Slides from the Readmissions Through Care Transitions Webinar and a Recording of the Readmissions Through Care Transitions Webinar are available.
(External Link) Caption: Recording
(PDF)
Associated Date: July 2011
Care Transitions Work Group Call April 14, 2011 Call Notes
Source: TAE
These are the notes from the Care Transitions Work Group Call on April 14, 2011.
(Word)
(PDF)
Associated Date: April 14, 2011
Partnership for Patients Webinar 1: Introduction to the Patient Safety Initiative & Standout Stories
Source: National Quality Forum
Slides from first webinar in the partnership for patients webinar series that took place on June 20, 2011. The session provided an overview of the Partnership for Patients initiative and set the context for the series of webinars to follow.
(PDF)
Associated Date: June 2011
ADRC Care Transitions Workgroup Call Slides - June 16, 2011
Source: AoA
AoA's PowerPoint Presentation for the June 16, 2011 Care Transitions Workgroup Call on the topic of Outcomes/Measurements Driving Sustainability.
(Powerpoint)
(PDF)
Associated Date: June 16, 2011
New York's Flow Chart for the CTI-Plus Program Pathway
Source: New York
This Flow Chart for the Care Transitions Intervention (CTI)-Plus Program Pathway was included in New York's SART report.
(Word)
Associated Date: May 2011
New York Care Transition Coach Forms
Source: New York
New York's Spring 2011 SART report included an example of a Care Transitions Coach In-Hospital Assessment Checklist as well as a Care Transitions Coach Home Assessment Form.
(PDF) Caption: In-Hospital Assessment Checklist
(PDF) Caption: Home Assessment Form
Associated Date: May 2011
New York's Community Supports Navigator Program
Source: New York
New York's Community Supports Navigator (CSN) program is an initiative that utilizes trained volunteers who, through a local volunteer organization, provide coaching support and advocacy for an older adult with a chronic disease(s) and their primary caregiver(s) who is transitioning from a hospital in-patient stay to the community.
(Word) Caption: Program Summary
(Word) Caption: Minimum Data Set for Program Enrollee Outcomes Tracking
(Word) Caption: Consumer/Caregiver Self-Management Capacity Form
Associated Date: December 2010
AoA Webinar: Building Community Technology Systems to Support Care Coordination
Source: AoA
Slides, transcript and audio recording of the AoA Care Transitions Webinar that took place on May 31, 2011. This webinar explores the role of technology in care coordination, discusses the building blocks of systems development, and presents a look at two communities actively engaged in this work.
(External Link) Caption: Website with audio link
(PDF) Caption: Transcript
(PDF) Caption: Slides
Associated Date: June 2011
A Care Transitions Collaboration (Maine)
Source: Maine
Maine created this document as a tool to share to help further explain the partnerships in Maine.
(PDF)
Associated Date: June 09, 2011
Community-Based Approach to Reducing Hospital Readmissions
Source: The Commonwealth Fund
Resources from The Commonwealth Fund webinar on May 6, 2011 including audio, speaker PowerPoint presentations, and links.
(External Link) • File type: web
Added June 6, 2011
AHRQ Innovations Excahnge (May 25, 2011 Issue): Cultural Competence
Source: 0
Tools and strategies on cultural competence from the May issue of the Innovations site from the Agency of Healthcare Research and Quality.
(External Link) Caption: AHRQ May 25, 2011 Issue: Cultural Competence
Added June 6, 2011
Cultural Competence:Essential Ingredient for Successful Transitions of Care
Source: National Transitions of Care Coalition
Fact sheet from the National Transitions of Care Coalition on the topic of cultural competency and the importance of cultural competency in the delivery of care transition services.
(PDF)
Added June 6, 2011
Massachusetts Care Transitions Sample Flow Chart
Source: Massachusetts
"Navigating Across Care Settings: Choices for Successful Transitions (NACS)"- Care Transitions Sample Flow Chart
(Powerpoint)
(PDF)
Associated Date: May 2011
South Carolina Hospital Discharge Planning Program Process Enhancement
Source: South Carolina
In October of 2008 South Carolina Lt. Governor’s Office on Aging was awarded an approximately $1.3M grant by Center on Medicare and Medicaid Services (CMS) to study, develop, and evaluate an ideal person-centered discharge planning process. The South Carolina Person Centered Discharge Planning (SC-PCDP) team was established including LGOA, the Appalachia Area Agency on Aging, University of South Carolina (USC), Community Long Term Care (CLTC), Spartanburg Regional Hospital System (SRHS), and other agencies and community stakeholder organizations. The team received person-centered training and created a core process committee to begin the study and development effort.
(PDF)
Associated Date: May 2011
Arkansas Care Transitions Program Brochure
Source: Arkansas
This Care Transitions Program Brochure was included in Arkansas' Spring 2011 SART report.
(PDF)
Associated Date: May 2011
Recap of CMS Special Open Door Forum on Partnership for Patients: The Community Based Care Transitions Program
Source: CMS
This Open Door Forum provides an overview of the Community Based Care Transitions Program (CCTP), answers to many previously received inquiries, and the opportunity for questions. The call took place on May 5, 2011.
(External Link) Caption: Information about subscribing to CMS Open Door Forum updates
(External Link) Caption: An mp3 recording an official transcript will be posted here on May 13, 2011
(External Link) Caption: An archived stream (available for 90 days)
Associated Date: May 2011
The GRACE Model: Geriatric Resources for Assessment and Care of Elders
Source: Dr. Steve Counsell, Indiana University
Plenary slides for the Grace Model.
(PDF)
Associated Date: February 2011
Maryland’s ADRC Evidence Based Transitions Grant Project: the Guided Care Model
Source: Maryland
Presentation on Maryland’s ADRC Evidence Based Transitions Grant Project: the Guided Care Model
(Powerpoint)
(PDF)
Associated Date: February 2011
Getting it Right the First Time: Person-Centered Care Transitions
Source: Dr. Eric Coleman, University of Colorado, Denver
Coleman - Care Transitions Plenary
(JPG)
Associated Date: February 2011
CCTP Program Application
Source: HHS
CCTP Program Application
(PDF)
Associated Date: April 2011
MOU between North Central Connecticut ADRC and Hospital of Central Connecticut
Source: Connecticut
This is an example MOU between the North Central Connecticut ADRC and The Hospital of Central Connecticut related to Care Transitions.
(Word)
(PDF)
Updated June 30, 2011
ADRC Care Transitions Workgroup Call April 14, 2011
Source: Administration on Aging
These are Caroline Ryan's slides for the Care Transitions Workgroup call held on April 14, 2011. They contain links to the Community-Based Care Transitions Program solicitation from CMS, information about ADRC care transitions programs and links to other resources and upcoming events.
(Powerpoint)
Associated Date: April 11, 2011
Data Update: ADRC Involvement in Hospital-to-Home Care Transitions April 2011
Source: TAE
This is an analysis of current Care Transitions activities through the October 2010 Semi-Annual Report. It describes sites currently active or planning care transitions activities.
(Word)
(PDF)
Added April 14, 2011
AoA Affordable Care Act Enews
Source: AoA
AoA Affordable Care Act Enews
Special Edition: Partnership for Patients
(External Link) Caption: Learn more about Partnership for Patients
(PDF)
Associated Date: April 2011
The Bridge Model - Program Summary
Source: Illinois Transitional Care Consortium
This document provides a summary of the evidence based care transitions model, the Bridge Model.
(PDF)
Added April 11, 2011
Care Transitions Evaluator Workgroup Call April 4th, 2011 Call Notes
Source: TAE
Notes from the April 4th, 2011 Option D Care Transitions Evaluator Work Group Call
(Word)
(PDF)
Associated Date: April 04, 2011
The Care Transitions Quality Improvement Organization Support Center
Source: Care Transitions Quality Improvement Organization Support Center (QIOSC)
An organization which assists Medicare Quality Improvement Organizations (QIOs) to promote seamless transitions from the hospital to home, skilled nursing care, or home health care.
(External Link) • File type: web
Updated April 1, 2011
Care Coordination Measures Atlas
Source: Agency for Healthcare Research and Quality
Prepared by the Agency for Healthcare Research and Quality (AHRQ) this document identifies more than 60 measures for assessing care coordination that include the perspectives of patients and caregivers, health care professionals and health system managers.
(PDF)
Associated Date: March 09, 2011
The GRACE Model: Geriatric Resources for Assessment and Care of Elders
Source: Dr. Steve Counsell, Indiana University
2011 National Meeting Session: Person-Centered Care Transitions: GRACE Model
(PDF)
Associated Date: February 15, 2011
Cross Cultural Strategies for Strengthening the Relationship between Hospital and Community Systems
Source: Robert Schreiber
The presentation given by Dr. Robert Schreiber, MD during the Evidence Based Care Transitions session at the 2011 National Grantee Meeting
(Powerpoint)
(PDF)
Updated April 12, 2011
Aging Care Connections, IL - Responding to the Care Transition Resource Challenges
Source: Aging Care Connections, Illinois
A presentation give by members of Aging Care Connections during the Responding to Care Transition Resource Challenges session at the 2011 National Grantee Meeting
(Powerpoint)
(PDF)
Associated Date: February 2011
Florida ADRC PSA 7: Care Transitions Program
Source: Sandi Smith
2011 National Grantee Meeting Session: Responding to Care Transition Resource Challenges
(Powerpoint)
(PDF)
Associated Date: February 16, 2011
Care Transitions - The Aging Network's Response
Source: Atlanta Regional Commission: Sue Burgess
2011 National Meeting Session: Responding to Care Transition Resource Challenges
(Powerpoint)
(PDF)
Associated Date: February 16, 2011
Technologies for Improving Post Acute Care Transitions and Preventing Hospitalizations
Source: Center for Technology and Aging: Lynn Redington
2011 National Meeting Plenary: Getting it Right the First Time: Person-Centered Care Transitions
(Powerpoint)
(PDF)
Associated Date: February 16, 2011
Project BOOST
Source: Dr. Eric Howell
2011 National Meeting Session: Person-Centered Care Transitions
(PDF) • File type: doc
(Powerpoint) • File type: doc
Associated Date: February 15, 2011
Your Discharge Planning Checklist: For patients and their caregivers preparing to leave a hospital, nursing home, or other health care setting
Source: CMS
2011 National Meeting Session: Identifying Nursing Facility Residents who Want Out: The Alphabet Soup of LCAs, MDS, MFP, and ADRCs
(PDF)
Associated Date: April 2010
Responding to the Care Transition Resource Challenges
Source: Aging Care Connections, Illinois
2011 National Meeting Session: Responding to Care Transition Resource Challenges
(PDF) • File type: doc
(Powerpoint) • File type: doc
Associated Date: February 15, 2011
Care Transitions: What Do These Programs Look Like? And How Can ADRCs Play a Role?
Source: Caroline Ryan
Caroline Ryan's presentation during the Introduction to Evidence-Base Care Transitions Models session at the 2011 National Grantee Meeting
(Powerpoint)
(PDF)
Updated June 30, 2011
Care Transitions in New Hampshire
Source: Laura Davie
Laura Davie's presentation during the Introduction to Evidence-Base Care Transitions Models session at the 2011 National Grantee Meeting.
(Powerpoint)
(PDF)
Updated June 30, 2011
Care Transitions and AoA’s Evidence-Based Health Programs
Source: AoA: Jane Tilly
Jane Tilly's presentation for the Integrating Care Transitions and Person-Centered Health Programs session at the 2011 National Grantees Meeting.
(Powerpoint)
(PDF)
Associated Date: February 2011
Connecticut’s ADRC Approach to Integrating the Care Transition Intervention Model & Chronic Disease Self Management Program
Source: Daniel Flynn
Daniel Flynn's presentation for the Integrating Care Transitions and Person-Centered Health Programs session at the 2011 National Grantees Meeting.
(Powerpoint)
(PDF)
Associated Date: February 2011
Navigating Accross Care Settings: Choices for Successful Transitions
Source: Valerie Parker Callahan
Valerie Parker Callahan's presentation for the Integrating Care Transitions and Person-Centered Health Programs session at the 2011 National Grantees Meeting.
(Powerpoint)
(PDF)
Associated Date: February 2011
The Bridge Model: An Innovative Social Work Approach to Transitional Care
Source: Illinois Transitional Care Consortium
2011 National Meeting Training: Person-Centered Care Transitions
(Powerpoint)
Associated Date: February 15, 2011
Connecticut Care Transition Intervention Book
Source: North Central CT Community Choices
A summary of the objectives, rationale, implementation and protocols for the North Central Connecticut Community Choices ADRC's Care Transition Intervention Initiative.
(PDF)
Associated Date: December 21, 2010
CMS Community Based Care Transitions Demonstration Website
Source: Centers for Medicare and Medicaid Services
CMS maintains this webpage with information about the Community Based Care Transitions Program (CCTP). The goals of the program 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. The demonstration will be conducted under the authority of section 3026 of the Affordable Care Act of 2010. Also included is the agenda and presentations from the December 3rd, 2010 National Conference on Care Transitions.
(External Link)
(PDF) Caption: Conference Agenda
(PDF) Caption: Community-Based Care
(PDF) Caption: Hospital Implementation
(PDF) Caption: Intervention Model Implementation
(PDF) Caption: LTC Transition Models
(PDF) Caption: QIOSC
(PDF) Caption: Transitional Care Model
(PDF) Caption: Application Budget Worksheet
Associated Date: December 13, 2010
Person-Centered Transitional Care, North Carolina
Source: North Carolina
This presentation describes North Carolina’s Community Connections program and its goal of developing a model of collaborative community-based services. These results of a mid-point evaluation of Community Connections demonstrate the progress that had been made to facilitate access to services and supports for consumers during transitions, especially from hospital to home.
(Powerpoint)
Added August 5, 2010
Forsyth “Hospital to Home Program for Older Adults”
Source: North Carolina
In this presentation staff of the Forsyth Medical Center and the Forsyth Medical Center Foundation in North Carolina present an overview of their activities implementing a Person-Centered Hospital Discharge Planning program in North Carolina. The “Hospital to Home Program for Older Adults is being conducted by Forsyth Hospital which is participating in North Carolina’s PCHDM initiative. The Forsyth Hospital transition program is based on the Coleman Model. North Carolina’s CRCs are building on existing relationships established by the Community Care Network to expand the program’s engagement with critical pathway providers.
(Powerpoint)
Added August 5, 2010
California ADRC Care Transitions Intervention Implementation Booklet
Source: California Health and Human Services Agency
This implementation booklet (copyrighted version) is intended to assist ADRC staff and partners in the successful implementation of the Improving Care Transitions project for sites in California. The booklet covers the core components and tools of the Care Transitions Intervention implementation process: ADRC CTI Work Plan, Four Pillars, Care Transitions Intervention Tools and Forms, Sample Transition Coach Visit Sequences and Scripts, Data Collection Measures, Project Reports, Sample Patient Consent Form, and Project Dates.
(Word)
Updated August 5, 2010
Care Transitions Workgroup Call Notes, June 17, 2010
Source: Technical Assistance Exchange
These notes summarize the dialogue from the Care Transition Workgroup on June 17, 2010. The subject of the call was collaboration with Quality Improvement Organizations (QIOs).
(Word)
(PDF)
Associated Date: June 17, 2010
Stepping Stones Care Transitions Fact Sheet
Source: Qualis Health
The Care Transitions Prject of Whatcom County, Washington, is aimed at eliminating unnecessary readmissions to its local hospital. This fact sheet outlines goals, strategies, and partners.
(PDF)
Added June 25, 2010
Coaching Patients to Improve Care Transitions in Pennsylvania: QIO/Area Agency on Aging Partnership
Source: Naomi Hauser
Naomi Hauser from Quality Insights of Pennsylvania gave this presentation on the Care Transitions work group call on June 17, 2010.
(Powerpoint)
Associated Date: June 17, 2010
Care Transitions Project Overview
Source: Jane Brock
Jane Brock from the Colorado Foundation for Medical Care gave this presentation on the Care Transitions work group all on June 17, 2010.
(Powerpoint)
Added June 17, 2010
Care Transitions Workgroup: “ADRCs and QIOs: Potential Partners in Care Transitions”
Source: Technical Assistance Exchange
Kip Brown's introductory presentation for Care Transitions work group call on June 17, 2010.
(Powerpoint)
Updated July 13, 2010
Stregthening Services for Older Adults through Changes to the Older Americans Act
Source: New York Academy of Medicine & National Coalition on Care Coordination
The Social Work Leadership Institute of the New York Academy of Medicine and the National Coalition on Care Coordination developed recommendations that consider how to strengthen care coordination in the 2011 reauthorization of the Older Americans Act (OAA). The recommendations enhance provisions for care coordination that link health/medical and long-term care and social support services.
(PDF) Caption: Report
(PDF) Caption: Appendix A
(PDF) Caption: Appendix B
(PDF) Caption: Appendix C
(PDF) Caption: Appendix D
(PDF) Caption: Appendix E
Added June 17, 2010
Identifying Target Populations for the Community Supports Navigator Initiative
Source: NY Connects
The New York State Office for the Aging developed this brief for its care transitions program. The brief discusses recent research on who has high readmission rates from a sub-acute inpatient or emergency room event.
(PDF)
(Word)
Added June 9, 2010
NY Connects Care Transitions Community Supports Model
Source: NY Connects
This pictogram from NY Connects demonstrates how the ADRC can help an individual successfully transition from an acute care setting.
(PDF)
Added June 9, 2010
Structuring, Financing, and Paying for Effective Chronic Care Coordination
Source: The National Coalition on Care Coordination (N3C)
This paper explores options for structuring, financing and paying for care coordination that span the medical care and social support dimensions. It draws from research and demonstrations on the traditional fee-for-service Medicare population that focus on the medical dimension and also from research and demonstrations from Medicaid, Medicare Advantage, and programs of the Administration on Aging that have studied long-term services and supports not covered by traditional Medicare.
(PDF)
Added April 21, 2010
ADRC Care Transitions Profile - April, 2010: West Virginia ADRC
Source: Technical Assistance Exchange
This profile details the West Virginia Aging & Disability Resource Center’s (ADRCs) efforts on care transitions. The program has just started operations as of mid-March, 2010. This profile describes, among many program details, information on the program’s hospital partnerships, the care transitions model they use and their plans for sustaining their care transitions program.
(Word)
(PDF)
Associated Date: April 2010
ADRC Care Transitions Profile - April, 2010: Northeast Georgia ADRC
Source: Technical Assistance Exchange
This profile details Northeast Georgia ADRC’s efforts on care transitions. The program has recently started operations (March 2010). This profile describes, among many program details, information on the program’s hospital partnership, the care transitions model they use and their plans for sustaining their care transitions program.
(Word)
(PDF)
Associated Date: April 2010
ADRC Care Transitions Profile - April, 2010: 10B AAA, Ohio
Source: Technical Assistance Exchange
This profile details the Ohio based 10B Area Agency on Aging’s efforts on care transitions. 10B currently enrolls consumers in Ohio’s PASSPORT Medicaid Waiver services and is now integrating the Care Transitions Intervention into these efforts. The program has not served consumers through the Care Transitions Intervention as of April, 2010. This profile describes, among many program details, information on the program’s hospital partnerships and the care transitions model they will use.
(Word)
(PDF)
Associated Date: April 2010
ADRC Care Transitions Profile, April 2010 - Central Texas ADRC
Source: Technical Assistance Exchange
This profile details Central Texas ADRC ‘s efforts on care transitions. The program has served over 200 consumers through its care transitions efforts as of April, 2010. This profile describes, among many program details, information on the program’s hospital partnership, the care transitions models they use, evaluation metrics (including costs and readmission rates) and their plans for sustaining their care transitions program.
(Word)
(PDF)
Associated Date: April 2010
Care Transitions Workgroup Notes from the National Grantee Meeting, February 2010
Source: Technical Assistance Exchange
These notes summarize discussion from the breakfast meeting of the Care Transitions Workgroup at the 2010 Grantee National Meeting in Alexandria. Participants discussed their work in transitions to date and what resources would be most beneficial going forward.
(Word)
(PDF)
Associated Date: February 24, 2010
Coaching Older Adults to Assert a More Active Role During Transitions: The Care Transitions Intervention
Source: Dr. Eric Coleman, University of Colorado
These slides from Dr. Eric Coleman entitled Coaching Older Adults to Assert a More Active Role During Transitions: The Care Transitions Intervention were provided as part of the 2010 National Meeting during the session Care Transitions and Person-Centered Hospital Discharge Planning Models.
(PDF)
Updated March 2, 2010
Idaho Real Choices: Rural Hospital Discharge Model
Source: Idaho
This handout from Idaho was provided at the 2010 National Meeting in a session entitled Developing a Care Transitions Program - Two States Discuss Emerging Models and Best Practices.
(Word)
(PDF)
Updated March 2, 2010
NY Connects Community Supports Navigator
Source: NY Connects
This is the Power Point presentation by Stacey Agnello, Lisa Holmes and Erin Stachewicz given at the 2010 National Meeting during the session entitled Developing a Care Transitions Program - Two States Discuss Emerging Models and Best Practices.
(Powerpoint)
(PDF)
Updated March 2, 2010
The Central Texas ADRC and Community Living Program
Source: Texas
This is the Power Point presentation by H. Richard McGhee and Alan B. Stevens given at the 2010 National Meeting during the session entitled The Central Texas ADRC and Community Living Program.
(Powerpoint)
(PDF)
Updated March 2, 2010
Developing a Care Transitions Program: Two States Discuss Emerging Models and Best Practices
Source: TAE
This is the Power Point presentation entitled "Developing a Care Transitions Program: Two States Discuss Emerging Models and Best Practices" by Kip Brown given at the 2010 National Meeting.
(Powerpoint)
(PDF)
Updated March 2, 2010
Person-Centered Hospital Discharge and Care Transitions
Source: Idaho
This is the Power Point presentation by Russell Spearman and Debra Larsen given at the 2010 National Meeting during the session entitled Developing a Care Transitions Program - Two States Discuss Emerging Models and Best Practices.
(Powerpoint)
(PDF)
Updated March 2, 2010
Care Transitions Workgroup Presentation, December 16, 2009
Source: Technical Assistance Exchange
These slides used on the December 16th Care Transitions Workgroup Call describe various models of Care Transitions Interventions.
(Powerpoint)
(PDF)
Associated Date: December 16, 2009
Care Transitions Workgroup Call Notes, December 16, 2009
Source: Technical Assistance Exchange
These call notes summarize discussion from a December 2009 workgroup on care transitions models.
(PDF)
(Word)
Associated Date: December 2009
Care Transitions Workgroup Call Notes, October 29, 2009
Source: Technical Assistance Exchange
These call notes describe the conversation of the Care Transitions Workgroup on October 29, 2009. The topic of the call was gaining hospital buy-in for partnering with the ADRC for care transitions interventions.
(PDF)
(Word)
Associated Date: October 29, 2009
Care Transitions Workgroup Call Notes, September 30, 2009
Source: Technical Assistance Exchange
These call notes summarize the dialogue that took place during a teleconference meeting of a Care Transitions workgroup. Texas and Florida shared information about their experiences implementing care transitions programs through CLP, and others on the call discussed targeting and assessment.
(PDF)
(Word)
Associated Date: September 30, 2009
Brochure Describing Central Texas ADRC’s CLP/Care Transitions program
Source: Texas
In additional to describing the geographic and functional eligibility criteria for receiving services, this resource lists the upper limits on a consumer’s income and assets to determine if it is appropriate for a consumer to be placed in Central Texas ADRC’s Care Transitions program. There are no lower limits of income and assets for the program except if the consumer reaches the point of being eligible for Medicaid.
(PDF)
Added September 29, 2009
Screening Criteria for Central Texas ADRC’s CLP/Care Transitions program
Source: Texas
These screening questions target consumers that require help with ADL functioning, have a memory impairment that makes living alone difficult, have a caregiver, have medical needs and are at risk of Medicaid spend down. The Charlson Comorbidity Score is used to determine medical needs. The screening criteria contain two Tiers of questions. For patients identified in the hospital, screening and enrollment occur in two Tiers, and occurs only in Tier 2 for patients identified in the community.
(Word)
Added September 29, 2009
ADRC/CLP Protocols - Florida
Source: Florida
Protocols recently modified for Florida's 2008 CLP grant award project. These include protocols on identifying consumers, the initial consumer assessment and screening consumers for functional and financial eligibility. States implementing Care Transition programs can learn details about Florida’s process for screening individuals’ functional and financial status. States can also learn from Florida’s use of income and asset screening as well as the use of income/asset minimums and maximums as financial targeting criteria.
(Word)
Added September 29, 2009
Form 701B Screening Instrument – Florida
Source: Florida
Comprehensive face-to-face assessment before a program initiates relevant aging services and forms the basis for the care plan development. Similar to the 701A, it screens for functional status and financial resources in Florida’s CLP and ADRC Care Transitions programs.
(PDF)
Added September 29, 2009
Form 701A Screening Instrument - Florida
Source: Florida ADRC and CLP
Screening instrument for determining an individual's priority for aging services so that those in greatest need and with the least assistance available will receive services first. This screening is usually completed over the telephone. Even though targeting criteria differ between the programs, both Florida’s CLP and ADRC Care Transition programs use this form to gather financial information for eligibility screening.
(PDF)
Updated May 26, 2010
Standards for Targeting Individuals at Risk of Medicaid Spend Down
Source: Administration on Aging
Many states involved in Care Transitions are concerned with screening for a consumer’s risk of becoming eligible for Medicaid spend down. While this document was originally written for Community Living Programs (CLP), Care Transitions programs from ADRCs can also use it to think through how income and asset tests might work in their program.
(External Link) • File type: doc
Added September 29, 2009
Project Boost Tool for Addressing Risk: A Geriatric Evaluation for Transitions
Source: Better Outcomes for Older Adults Through Safe Transitions
A user-friendly assessment tool meant to screen for risk of re-hospitalization, emergency room visits or other adverse events. The tool is completed at admission and is based on seven dominant patient-specific risk factors: problem medications, depression, principle diagnosis, polypharmacy (consumer on five or more medications), poor health literacy, patient support (formal or informal caregiver), and prior hospitalizations in the past month.
(External Link) • File type: pdf
Added September 29, 2009
ADRCs Potential Role in Care Transitions
Source: Technical Assistance Exchange
This presentation on the the role of ADRCs in care transitions was given at the Care Transitions Work Group September 2009 Monthly Call.
(Powerpoint)
(PDF)
Updated June 21, 2010
Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions
Source: Institute for Healthcare Improvement
This document is intended to provide a sampling of the range of effective programs underway to reduce avoidable rehospitalizations across the US. In total, 15 programs are highlighted in this document: four with very strong trial or evaluation evidence of effectiveness, seven with very good evidence of reduction in rehospitalization rates, and four that are promising interventions but require further data.
(External Link) • File type: pdf
(PDF)
Added September 3, 2009
Patient Centered Medical Home
Source: 0
The following resources provide information for physicians on becoming a patient centered medical home.
(External Link) Caption: MedicalHomeInfo.org • File type: web
(External Link) Caption: PPC-PCMH Fact Sheet • File type: web
(External Link) Caption: Patient Centered Medical Home • File type: web
Added August 28, 2009
The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses
Source: Mathematica Policy Research, Inc.
This report was commissioned by the National Coalition on Care Coordination (N3C) to synthesize the evidence on cost-effective interventions and their essential components, identify key issues that still must be resolved for ongoing research, and present recommendations for care coordination policies in health care reform that can be supported by the currently available evidence base.
(External Link) • File type: pdf
Added August 28, 2009
CMS Resources Relating To Care Coordination
Source: Centers for Medicare & Medicaid Services
The following resources provide information relating to CMS efforts in care coordination.
(External Link) Caption: CMS Fact Sheet – QIOs and Care Transitions • File type: pdf
(External Link) Caption: List of QIOs Involved in Care Transition • File type: web
(External Link) Caption: CARE Tool User Manual for QIOs • File type: pdf
(External Link) Caption: 9th Statement of Work for QIOs • File type: web
(External Link) Caption: CMS Discharge Checklist
Added August 28, 2009
New Study on Hospital Readmissions
Source: Office of Management and Budget
Office of Management and Budget Peter Orszag’s blog post announcing care transitions as a priority for the Obama Administration.
(External Link) • File type: web
Added August 28, 2009
Cross walk: Re-Engineered Discharge, Project BOOST, Coleman’s Transitions
Source: Oregon
This cross walk compares the characteristics of the Re-Engineered Discharge, Project BOOST, Coleman’s Care Transitions models.
(Word)
(PDF)
Added August 27, 2009
Real Choice Systems Change Grant - Oregon's Person-Centered Hospital Discharge Planning Model
Source: Oregon
This presentation describes the features and desired outcomes of Oregon's Person-Centered Hospital Discharge Planning Model.
(PDF)
(Powerpoint)
Added August 27, 2009
Oregon Hospital Discharge Feedback Survey
Source: Oregon
This is a hospital discharge feedback form used to evaluate Oregon’s Person-Centered Hospital Discharge Planning Model. The form assesses the patient’s level of understanding and confidence to follow instructions upon discharge from the hospital. The form also assesses the patient’s success in scheduling a follow-up appointment and how well the hospital supports caregivers.
(PDF)
(Word)
Updated April 6, 2010
Kansas Person-Centered Hospital Discharge Model - Fact Sheet
Source: Kansas HDM/ADRC
This document summarizes Kansas's activity under their 2008 Person-Centered Hospital Discharge Planning Model Grant from CMS. The document summarizes the Kansas Hospital Discharge Planning Model's target population, pilot locations, key partners, project goals, measureable outcomes and project timeline.
(Word)
(PDF)
Updated June 2, 2010
The Commonwealth Fund: Chronic Care Management
Source: The Commonwealth Fund
The Commonwealth Fund sponsored this study published in Health Affairs. It found that chronic care management programs that use multidisciplinary clinician teams and in-person communication can reduce hospital re-admissions.
(PDF)
Updated April 27, 2010
Planning for Your Discharge - Guide from CMS
Source: CMS
CMS published this guide to help caregivers, patients and staff plan discharges from health care settings.
(Word)
(PDF)
Updated August 27, 2009
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