Grantee-Created Care Transitions Resources
Resource Filtering Instructions: Click on any circular icon at the top of this page to display only resources with that attribute. Click on the orange "All" icon to restore the full list of resources.
WA AAA Care Transitions Toolkit 
Source: WashingtonThe 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 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
TAE
About the Technical Assistance Exchange 
