Care Transitions

Person-Centered Hospital Discharge Planning

The Person-Centered Hospital Discharge Planning project was focused on discerning the role of the ServiceLink Resource Center (SLRC) Network in hospital-to-community transitions and providing support to SLRC sites and their local hospital in developing formal partnerships. In some cases, this work resulted in supporting implementation of care transitions models. A statewide stakeholder workgroup actively participated to shape this project.

Evidence-based Care Transitions Pilot Program

CACL provided implementation support and program evaluation to three ServiceLink Resource Centers (SLRC) through an Administration on Aging and Affordable Care Act of 2010 funded evidence-based care transitions grant. The Care Transitions Intervention model (Coleman) was implemented at Carroll County SLRC, in partnership with The Memorial Hospital and at Monadnock SLRC, in partnership with Cheshire Medical Center/Dartmouth Hitchcock Keene. The Better Outcomes for Older adults through Safe Transitions (BOOST) model was implemented at Belknap County SLRC in partnership with Lakes Region General Healthcare. The programs continue to develop and expand.

New Hampshire Money Follows the Person

The NH Bureau of Elderly and Adult Services contracted with CACL to provide project management and technical assistance on this statewide program. This program was part of the Centers for Medicare and Medicaid Services' Money Follows The Person (MFP) Rebalancing Demonstration Grant.

Partnership for Care Transitions Workgroup

In 2009, a statewide workgroup was formed under NH’s Aging and Disability Resource Center grants for evidence based care transitions models. The multi-stakeholder group informed the role of ServiceLink Aging and Disability Resource Centers transitions pilot projects in three NH communities with partner acute care hospitals. After the pilot ended, the workgroup evolved and continues to meet on a quarterly basis to discuss and collaborate on care transitions models being implemented throughout New Hampshire. Anyone is welcome to participate. If you are interested in attending the workgroup, email Laura Davie.