1. ADRC Care Transitions Workgroup Call April 14, 2011 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL aoainfo@aoa.gov | WEB www.aoa.govaoainfo@aoa.gov

2. Agenda Welcome and Introductions Community Based Care Transitions Program Solicitation Expansion of ADRC Care Transitions Activities Discussion about Partnerships Care Transitions Resources and Upcoming Events U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL aoainfo@aoa.gov | WEB www.aoa.gov

3. Community Based Care Transitions Program Solicitation: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_Solicitation.pdf http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_Solicitation.pdf Applications will be accepted and reviewed on a rolling basis. Acceptable applicants will be awarded on a first come, first serve basis as funding permits.

4. AoA Affordable Care Act: Opportunities for the Aging Network: http://www.aoa.gov/AoARoot/Aging_Statistics/Health_care_reform.aspx http://www.aoa.gov/AoARoot/Aging_Statistics/Health_care_reform.aspx SAVE THE DATE! AoA Webinar About Solicitation April 20 Stay Tuned for More Details

5. Hawaii * Alaska * MT ID WA † CO † WY NV CA *† NM AZ MN TX † KS * IA WI IL † KY TN † IN † OH MI ALMS AR LA FL † SC * WV VA NC* PA † VT RI † NH † OR * UT SD ND MO * OK NE NY † CT † MA † DC ADRC Care Transitions Activities DE Guam Northern Mariana Islands 30 States with ADRC program sites currently conducting care transitions through formal intervention ( Total of 48 active sites with an additional 55 sites within active states currently planning to conduct care transitions) 14 States with ADRC program sites currently planning to conduct care transitions through formal intervention ( Total of 21 sites currently planning care transitions activities within states with no active sites) GA 10 States not reporting current or planned care transition activities Puerto Rico * Indicates state with current CMS Hospital Discharge Planning Model grant † Indicates state with 2010 ADRC care transitions grant MD *† NJ ME †

6. ADRC Care Transitions Expansion Expansion of Activity since April 2010: 38 sites are now active that previously were either planning or had not reported any Care Transition activity. Evidence-based models. – 17 sites use Eric Coleman’s Care Transitions Intervention (CTI) model or aspects of the model – 1 site each using Transitions Case Management (TCM) model; GRACE model; Guided Care model. – 29 sites planning on using the CTI model, 1 planning to use the BRIDGE model, and 1 site planning to use the BOOST model. In the Fall 2010 SART narratives, a common challenge identified by ADRC grantees was developing and maintaining strong partnerships with hospitals

7. Discussion about Partnership Successful outreach and communication strategies? – What works well when reaching out to prospective partners: hospitals, QIOs, community-based organizations? Partnership lessons learned? – What facilitates strong, productive partnerships and successful programs?

8. Care Transitions Resources and Upcoming Events April 20 Webinar about CCTP Solicitation: http://www.aoa.gov/AoARoot/Aging_Statistics/Health_care_reform.aspx http://www.aoa.gov/AoARoot/Aging_Statistics/Health_care_reform.aspx The American Society on Aging annual conference, San Francisco, April 26-30 http://www.agingconference.org/AiA11/index.cfm http://www.agingconference.org/AiA11/index.cfm AoA Webinar Series Feedback – What’s been most useful about the series? – What other topics would you like to see addressed? ADRC TAE Care Transitions Discussion Forum: http://www.adrc-tae.org/tiki-view_forum.php?forumId=7 http://www.adrc-tae.org/tiki-view_forum.php?forumId=7 Next Meeting and Topics for this Workgroup – What would you like to discuss with peers?