The Administration on Aging has released a very useful Care Transitions Toolkit to help healthcare organizations improve the quality of care transitions for senior patients. The Toolkit is in the form of a series of free PDF files that explain various issues that affect care transitions quality. You can download "The Aging Network and Care Transitions: Preparing your Organization Toolkit", at https://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/Toolkit/index.aspx.
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. Whether your organization has historically developed partnerships with health care providers or programs that span the continuum of care such as Community Living, Money Follows the Person, Aging and Disability Resource Centers, or others, the tools and resources here can assist in formalizing your efforts for future funding and program opportunities.
This toolkit includes lessons learned from States that received funding from the Aging and Disability Resource Center (ADRC) Program, ADRC Evidence-Based Care Transitions Program, Person-Centered Hospital Discharge Model, Community Living Program (CLP), and the Veteran Directed Home and Community Based Services (VD-HCBS) Program.
To find other helpful resources for improving the quality of care transitions, use the Care Transitions Search Widget, developed by Growth House specifically to locate high-quality content related to care transitions and reducing hospital readmissions.