Relevant Resources

There are a lot of helpful resources online for organizations interested in learning more about care transitions, social work, and integrating medical and social care.

  1. Administration on Community Living (ACL):  The Administration on Community Living (including the Administration on Aging) offers many resources on best practices for community-integrated care.
    1. Administration on Aging Care Transitions Webinars:  Webinars on best practices around transitional care, such as working with the Aging Network.
    2. ACL’s Evidence-Based Care Transitions Programs:  Information on evidence-based care transitions programs and further transitional care resources.
  2. National Transitions of Care Coalition (NTOCC) Multiple tools to help consumers, professionals, policy makers, and the media understand, navigate, and improve transitions of care.
  3. National Association of Social Workers (NASW) Highlights the importance of social work in transitional care, in particular in addressing the many biopsychosocial challenges related to transitions of care.
  4. National Coalition on Care Coordination (N3C) Resources for  policy makers on best practices for transitional care.
  5. Consumers Advancing Patient Safety (CAPS) Transitions Toolkit: Toolkit to guide consumers through hospital discharges and to support them in communicating with their health care providers before, during, and after discharge.
  6. Integrating Care for Populations & Communities – Care Transitions Toolkit: This toolkit is provided  through the Quality Improvement Organizations National Coordinating Center’s Integrating Care for Populations & Communities aim. The toolkit contains helpful information for designing and implementing care transitions programs. This website also provides other resources on transitional care, including a webinar series and recent readmission rates by zipcode.
  7. Community-based Care Transitions Programs (CCTP): Comprehensive list and map of 102 awarded collaborations around nation participating in CCTP, an initiative authorized by the Affordable Care Act (section 3026) to test community-driven efforts to prevent hospital readmissions.