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Resources for Care Transition Programs

People living in institutions face higher rates of infection and death due to COVID-19. Concerns about infection control in congregate settings during the pandemic are increasing referrals to the aging and disability networks to help people in nursing homes, skilled nursing facilities, hospitals and other settings transition to the community. (Source)

In response, ACL-funded networks are using a number of innovative approaches to connect people to the home- and community-based services they need once they return home.

This page provides helpful strategies and resources for Centers for Independent Living (CILs), Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs), hospitals, and other organizations that play an important role in supporting transitions from one setting to another during the pandemic.

This page will be updated with resources and examples of innovative approaches as we learn of them. If your organization would like to share your strategies, please contact

We hope this information helps you plan for and implement successful transitions for the people you serve.

Innovative Practices from the Field

ACL-funded aging and disability network organizations and health care providers are implementing innovative approaches to transitions during the COVID-19 pandemic. You will find examples of these creative and leading-edge approaches to transitions below.


Care Transitions Peer Hour Featuring Elder Services of the Merrimack Valley and Greater Lynn Senior Services (March 31, 2021)

This call recording features representatives from two community-based organizations from the Commonwealth of Massachusetts. Learn how AAAs and ADRCs address social determinants of health as part of the MassHealth Community Partners (CP) Program, a value-based payment model.

How CILS Can Initiate Emergency Relocations and Transitions During the COVID-19 Pandemic (March 11, 2021) 

This training shared information on staffing, funding, and community partnerships utilized to build emergency relocation programs that offer safe alternatives to nursing homes and other congregate settings. Presenters highlighted examples of challenges faced and ongoing efforts to overcome these challenges.

Care Transitions Peer Hour Featuring Michigan Region IV AAA (December 1, 2020)

On this call recording, the Michigan Region IV AAA discusses strategies and promising practices that address care transitions start-up funding, outcomes tracking, and defining return on investment for their healthcare provider partners.

Care Transitions Peer Hour Featuring Partnerships in Alabama (October 22, 2020)

On this call recording, the Southern Alabama Regional Council on Aging (SARCOA) describes how they built their transition program including how they encouraged and leveraged the collaboration among the AAA, the Alabama Department of Senior Services, and Alabama Medicaid Agency, to expand access to Medicaid Home and Community-Based Waivers and other program services during the pandemic.

Care Transitions Peer Hour Featuring Georgia CILs and AAAs (September 15, 2020)

On this call recording, Walton Options for Independent Living, Northwest Georgia AAA, and the Atlanta Regional Commission share how they successfully adapted their institutional transitions work in response to the challenges they faced during the COVID-19 pandemic.

Care Transitions Peer Hour Featuring Multnomah County AAA (September 8, 2020)

On this call recording, Multnomah County AAA care transitions staff provide an overview of the current challenges impacting care transitions services and highlight their strategies and experiences in adapting their intervention during the pandemic, resulting in their ability to receive compensation for their efforts.


Progress Report on the Pilot Initiative to Provide Long-Term Care Options Counseling: Iowa Return to Community

This report was compiled by the Iowa Department of Aging to detail the progress of the Iowa Return to Community (IRTC) Initiative, a pilot initiative to provide long-term care options counseling utilizing support planning protocols. Using evidence-informed interventions, IRTC provides long-term care support planning to assist non-Medicaid eligible seniors who want to return to the community following a hospital or nursing facility stay.

Adapting Care Transitions Amidst Pandemic

This article presents an overview of Fast Track Home, the care transitions program of the Council on Aging of Southwestern Ohio. Included are links describing how the Council on Aging is adapting services to respond to the changing needs of older adults and people with disabilities during the COVID-19 crisis including new opportunities for community-based organizations.

COVID-19 Care Transitions Spotlight: Southern Alabama Regional Council on Aging

This spotlight features SARCOA discussing their non-profit corporation, Community Care Solutions (CCS), and the work they are doing to sustain their care transitions program beyond the Centers for Medicare & Medicaid Services (CMS) Innovation Center Community Care Transition Program (CCTP) demonstration.

COVID-19 Care Transitions Spotlight: Western New York Integrated Care Collaborative, Inc.

This spotlight on the Western New York Integrated Care Collaborative, Inc. (WNYICC) provides information on the work they are doing to sustain their care transitions program before and during the COVID-19 pandemic.

Hospital to Home: A Collaborative Between Community Partners Two-Part Series

In Colorado, the Independence Center’s Hospital to Home (H2H) program facilitates successful transitions to home for individuals with complex or difficult discharges. Part one of the series addresses the concept and vision of the H2H program and part two describes the steps to set up a H2H program in your area.

Care Transitions Tools

Discharge Planning and Care Coordination During the COVID-19 Pandemic: Maintaining Services for Adults with Disabilities Who Live in Community Setting

This toolkit is designed to support nurses, social workers, case managers, and others conducting discharge planning and care coordination for adults with disabilities who received care or treatment for COVID-19 illness in an acute care setting, are no longer COVID-19 positive, and require continuation or reconnection to supports and services. 

Health Care Person-Centered Profile

During COVID-19, people with communication, comprehension, and behavioral challenges may face the possibility of a hospital visit without their loved ones or usual supporters present. To address the challenges this poses, a group of experts in person-centered planning developed a tool that people with disabilities or older adults and their families and caregivers can fill out and share with medical staff to communicate their needs and preferences upon hospital admission or during transitions.

Care Transitions Resources

Care Transitions November Special Session: Starting a Hospital Care Transitions Program During COVID-19 (November 19, 2020)

This webinar shared best practices and strategies for establishing a hospital care transitions program during COVID-19, including the basics of beginning a program during COVID-19, connecting with hospitals in your area, and strategies to respond to hospital surges to ensure that individuals are connected to services and supports to safely transition home.

No Wrong Door Podcast: Supporting COVID-19 Challenges through Care Transitions Partnerships

On this podcast, Tim McNeill, consultant with Freedman’s Health, LLC, discusses best practices associated with care transitions amid the COVID-19 pandemic.

Federal Hospital Care Transitions Resources and the Aging and Disability Network

This document includes tools the aging and disability network can use to better facilitate transitions of care, with a heavy emphasis on hospital-to-home transitions and nursing home diversion activities.

COVID-19 Alternate Care Site Toolkit

This toolkit provides medical operations guidance for state, local, tribal, and territorial entities on operationalizing alternative care sites during the COVID-19 pandemic. Pages 21-22 and 26-27 are especially relevant to aging and disability networks that may partner with alternative care sites to coordinate care transitions for older adults and individuals with disabilities. 

National Center on Advancing Person-Centered Practices and Systems (NCAPPS)

The NCAPPS initiative promotes systems change that makes person-centered principles not just an aspiration but a reality for people who require services and supports across the lifespan. NCAPPS will assist States, Tribes, and Territories implement person-centered thinking, planning, and practice in line with U.S. Department of Health and Human Services policy including support for a range of person-centered thinking, planning, and practices, regardless of funding source.

No Wrong Door (NWD)

ACL, CMS, and the Veterans Health Administration (VHA) support states' efforts to develop coordinated systems of access to make it easier for consumers to learn about and access LTSS.

Care Transitions and Assistive Technology

Assistive technology (AT) is an important consideration for successful transition planning. Helping people connect to devices and resources that ensure successful transitions assists individuals in remaining in the home of their choice during COVID-19. Consultation with your state or territory AT program is a good way for transition programs to consider an individual’s needs prior to discharge.

State and territory AT programs continue to provide resources that allow individuals to transition from nursing facilities, hospitals, and other institutional based care to home and community-based settings. Key among those services is connecting individuals, caregivers, and providers to AT programs to offer demonstrations and trial periods of various devices and compare and contrast products to determine those that will best meet the specific needs of the individual. Through device reuse programs, AT programs are also able to provide gently used durable medical equipment that has been sanitized and refurbished, such as mobility and daily living devices. Often, device reuse programs can bridge the gap when equipment is needed promptly in the transition process. AT programs have alternative financing programs that include low-interest loans with flexible terms and, in some cases, other options that can assist with the affordability of needed devices and technology.

State Partnership Example: Missouri Assistive Technology (MoAT) 

MoAT worked with the Money Follows the Person program in Missouri to create an assistive technology demonstration service for individuals transitioning from nursing facilities to the community. Services include assistive technology, environmental accessibility modifications, and vehicle access modifications. 

AT3 Assistive Technology Toolkit

AT3 provides organizations that serve older adults and people with disabilities a range of tools to improve awareness about AT. This toolkit includes resources to help select and acquire technology and connect individuals with devices and service.

For more information about these and other activities, contact the AT program in your state or territory. More resources can be found on the AT3 Center Publications webpage.


Last modified on 05/15/2023

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