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The Aging Network and Care Transitions: Preparing your Organization Toolkit


Older adults experience more than 13 million transitions across the continuum of care a year. These transitions can be both dangerous and frustrating when there is insufficient coordination among professionals and/or information provided to patients and families. This toolkit was organized by the Administration on Aging to help health care organizations prepare for their role in care transitions programs. Additionally, this toolkit provides some perspectives for why care transitions programs provide a unique opportunity to address community approaches for supporting the health, independence, and choice of older adults, individuals with disabilities, and their caregivers.

Key Points

The toolkit is broken down into various chapters, providing background information on care transitions, taking time to plan, developing effective partnerships with health care providers, measuring for success, building organizational capacity, and implementation and day-to-day operations. This information is not only important but necessary considering that it is estimated that one in three Medicare recipients is readmitted to the hospital within 90 days of discharge, and between 40 and 50 of these readmissions are linked to lack of community resources and support.

Other report highlights include:

  1. It takes a coordinated, community based approach to improve hospital and nursing home transitions, and to support individuals in their communities. This approach includes health care and social service partners and has been recognized as an effective strategy to improve health and lower health care related costs.
  2. Strong community-wide partnerships with multiple health care stakeholders and other community based service providers are the backbone of a successful care transitions program.
  3. Chapter 2: Taking Time to Plan (page 8)

How to Use

While this toolkit is directed at organization leaders, it is a great resource for local officials interested in improving care transitions throughout their community because it provides information on formalizing efforts for future funding, program opportunities, and planning. Additionally, it has information from states that have received funding from the Aging and Disability Resource Center Program, as well as other sources, and it presents great case studies and lists important resources for finding additional information on a variety of topics related to care transitions.

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