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Long Term Care Discharge Planning

 

The New York State Department of Health, Division of Long Term Care, Office of Health Insurance Programs is providing online learning sessions detailing NYS long term care services and supports for discharge planners. In order to provide quality, cost effective health care, discharge planners must stay abreast of available services and resources to support patients in the community. Through these online education trainings and resources, discharge planners and other professionals involved in the discharge planning process will learn about new and enhanced initiatives that work together to support individuals in the community.

Obtain more information on long term care discharge planning directly from the NYS Department of Health. To obtain more information on long term care options, contact your local NY Connects program.

Archived Webcasts and Webinars

The Importance Of Stable Housing In Long Term Care: New York City Focus
(Originally presented on March 20, 2017)

The Importance Of Stable Housing In Long Term Care: Statewide Focus
(Originally presented on March 6, 2017)

The Money Follows the Person Program: Facilitating Return to Community-based Settings
(Originally presented on Thursday, February 16, 2017)

Transitional Care Partnerships: Improved Communication & Care Coordination Across the Healthcare Continuum
(Originally presented on Thursday, December 15, 2016)

Community First Choice Option (CFCO)
(Originally presented on Monday, June 27, 2016)

The Changing Face of Long Term Care in New York State
(Originally presented on Thursday, July 16, 2015)

The Winds of Change: The Evolving Long Term Care Environment
(Originally presented on Monday, October 26, 2015)

NY Connects: A Valuable Resource for Discharge Planners
(Originally presented on Tuesday, March 8, 2016)

Local Behavioral Health Systems in New York State
(Originally presented on Monday, June 20, 2016)

 

Community Resources
NY Connects
http://www.nyconnects.ny.gov

Independent Living Centers
http://www.acces.nysed.gov/vr/lsn/ilc/about.htm

State Resources
State Department of Health
https://www.health.ny.gov/professionals/patients/discharge_planning   http://www.health.ny.gov/health_care/medicaid/program/longterm/

State Office for the Aging
http://www.aging.ny.gov/ 

Centers for Medicare and Medicaid Services
http://cms.gov/

Patient/Family Education Resources  
Next Step in Care – number of lay language learning tools about proactive, self‐manager; expectations of different settings of care; how to participate in transitions planning – appropriate concerns, questions http://www.nextstepincare.org /

Medicare’s Discharge Planning Checklist for Patients and Caregivers – Action items for preparing for discharge, questions to ask
http://www.medicare.gov/Pubs/pdf/11376.pdf 

Transitions
Care Transitions Program – Dr. Eric Coleman’s work. http://www.caretransitions.org/ 

Transitions of Care (ToC) Portal – Joint Commission. http://www.jointcommission.org/toc.aspx 

CMS’ Partnership for Patients – Community‐based Care Transitions Program https://www.nyspfp.org/Members/Initiatives/Readmissions/Overview.aspx

National Transitions of Care Coalition. http://www.ntocc.org/ 

Administration for Community Living Care Transitions Toolkit. http://www.aoa.gov/AoA_Programs/HCLTC/ADRC_CareTransitions/Toolkit/index.aspx

For questions about the resources listed on the resource tab, please contact: Stacey Agnello, Program Advisor in the Division of Long Term Care at stacey.agnello@health.ny.gov.