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Center for Integrated Programs (CIP)

Office of Consumer Access and Self Determination

Evidence-Based Care Transitions Program

History and Background

Since ACL and CMS first began funding ADRC development in 2003, ADRCs have been working to assist individuals in “critical pathways,” which is defined as the times or places when people make important decisions about long-term care. This work included several innovative interventions to facilitate the hospital discharge process and to help nursing facility residents return to the community. The 2009 ACL program announcement for ADRCs, “Empowering Individuals to Navigate Their Health and Long-Term Support Options,” emphasized reaching people during transitions from one care setting to another by naming “person-centered hospital discharge planning” as a key operational component of an ADRC. In 2010, ACL built on these past investments to launch the ADRC Evidence Based Care Transitions Program. In 2012, ADRCs continue to build upon care transition infrastructure developed through these grant opportunities and are exploring sustainable support for these efforts.

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Purpose of the Program

When planning for discharge from the hospital or skilled nursing facility, individuals and caregivers often don’t know what support options are available or how to access community services. To address this important component of transitions, 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.

The 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 program is designed to promote the further development and enhancement of ADRC participation in evidence-based care transition models. This includes:

  • Increasing the capacity of the current involvement of ADRCs in evidence-based care transition initiatives by expanding the reach of the ADRC efforts (e.g., training staff, adding additional staff, expanding an intervention to serve new populations, or expanding to additional sites).
  • Strengthening the extent to which existing transitions programs operated by hospital and health systems leverage the assets of the ADRCs (e.g., to streamline access to public benefits, link individuals with community-based services and supports, and counsel individuals and their families on service options) among programs where ADRCs have a limited role currently.
  • 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.

The six evidence based care transition models being implemented by grantees include:

In 2010, ACL issued awards to 16 states implementing six different evidence based care transition models. Please select a state below for its project summary.

ADRC Evidence Based Care Transition Funded States and Selected Models map

The 2010 ADRC Evidence Based Care Transitions Program Announcement also included a special funding opportunity made available by The Center for Technology and Aging, with support from the SCAN Foundation, to support the use of assistive technologies in the Evidence-Based Care Transitions Programs funded through this program. For more information on this initiative, please refer to the program summary on the Center for Technology and Aging website (PDF).

Key program results to date include:

  • 22 ADRCs are partnering with 67 hospitals in 16 states
  • 20 ADRCs have supported the transition of 7,530 consumers
  • 16 ADRCs are partnering with Quality Improvement Organizations (QIOs)
  • ADRCs are also partnering with a myriad of other organizations, including:
    • Alzheimer’s Association Local Chapters
    • Accountable Care Organizations
    • Beacon Communities
    • Community Health Centers
    • Food Pantries
    • Health Care Facilities Associations
    • Health Homes
    • Health Information Exchanges
    • Home Health Agencies
    • Homeless Shelters
    • Hospital Associations
    • Hospital Engagement Networks (HENs)
    • Housing Organizations
    • Human Rights Agencies
    • Local Health Councils
    • Managed Care Organizations
    • Mental Health/Substance Abuse Providers
    • Patience Centered Medical Homes
    • Pharmacies and Pharmacy Associations
    • Physician Medical Organizations
    • Primary Care Providers
    • Protective Services
    • Public Health Departments
    • Quality Improvement Organizations
    • Rural Health Networks
    • State Health Insurance Programs
    • Skilled Nursing Facilities
    • Universities
    • Volunteer Organizations

For more information, please contact Caroline Ryan at

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Care Transitions and the Enhanced Options Counseling Program

As a result of ACL investments in ADRC care transitions activities, ADRCs across the country are serving as a resource for acute, primary and related health professionals and provide the healthcare system with a “single entry point” to community-based services and supports. ACL is building upon ADRC evidence based care transition experience through the Enhanced Options Counseling Program.

In 2012, ACL awarded ADRC Enhanced Options Counseling Program funding to eight states. The ADRC Options Counseling Program plays a pivotal role during transitions to ensure that people consider support and service options that best meet their individual needs and preferences. Local ADRC Options Counseling Programs will partner with local health systems to provide individuals and their families with transition support so they may make informed decisions and receive services quickly. These critical activities help individuals avoid being admitted unnecessarily to a nursing home or other institution. Quick connections to LTSS also break the cycle of avoidable hospital readmissions and improve individual outcomes in the community and quality of life.

Care Transitions Resources

ACL Resources
  • Template for Developing Care Transitions Success Stories (PDF, 0.5MB)
    This tool provides a basic framework to support the development of a brief story about a successful individual care transition experience. A good story confronts an urgent challenge faced by your community, taps into the values of community members to address the challenge and motivates individuals to take action in correction of that challenge.
  • The Aging Network & Care Transitions Toolkit
    This toolkit from AoA is targeted to organizations that are interested in learning more about how to prepare their organization for a role in care transitions. It includes case studies, resources and practical tools to assess your organization and plan for a care transition program.
  • Webinar Series: Care Transitions
    This initial series of webinars focuses on preparing the Network to participate in the Community-based Care Transition Program demonstration (Sec. 3026 of the Affordable Care Act).
  • Aging and Disability Resource Centers and Care Transitions
    The U.S. Administration on Aging sponsors this Exchange to make information and resources available to states and community organizations.
  • Health Reform Page
    This site provides access to the latest information on health care reform and the opportunity to learn how it impacts seniors and those with disabilities in your community.

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Other Resources
For Administrators
  • Care Transitions Quality Improvement Organization Support Center
    The Care Transitions Quality Improvement Organization Support Center (QIOSC) assists Medicare Quality Improvement Organizations (QIOs) to promote seamless transitions from the hospital to home, skilled nursing care, or home health care.
  • Centers for Medicare and Medicaid Services: Community-based Care Transitions Program
    The Community Based Care Transitions Program (CCTP) goals 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.
  • AHRQ Health Care Innovations Exchange
    The Innovations Exchange helps you solve problems, improve health care quality, and reduce disparities.
  • Center for Medicare and Medicaid Innovation
    The Innovation Center is a new engine for revitalizing and sustaining the Medicare, Medicaid and CHIP programs and ultimately to help to improve the healthcare system for all Americans. The Innovation Center, established by the Affordable Care Act, was given the flexibility and resources to rapidly test innovative care and payment models and scale up successful models.
  • 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.

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For Individuals and Families

Planning Ahead

Preparing for Discharge

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Last Modified: 7/7/2015