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# Care Transitions

Care transitions happen when an individual moves from one setting or location of care to another. These transitions can put older adults at risk for health issues, including malnutrition, but planning can help ensure that older adults and caregivers have the resources they need to transition safely. Meals and other nutrition services can be vital to successful care transitions. Understanding transitions can help you expand your program’s reach. 

## Guides

                    - Addressing Malnutrition in Older Adults During Care Transitions —MOWA  guide to understanding the impact of transitions across care settings and the risk of malnutrition  due to physiological, psychosocial, and economic factors                       - Report 
                    - Evaluating Malnutrition Care Coordination for Successful Patient Transitions — Resource from  the Academy of Nutrition and Dietetics on advancing  malnutrition care through adoption of electronic clinical quality measures
                    - Partnering to Integrate Health and Long-Term Care — Data and  early evidence from the Aging and Disability Business Institute on how community-based organizations partner with health care organizations

## Fact Sheets

                    - Better Integration of Malnutrition Care into Care Transitions is Necessary — Resource from the Academy of Nutrition and Dietetics, Avalere Health, and Defeat Malnutrition Today on integrating malnutrition care with care transitions

## Tools & Toolkits

                    - Care Transitions Intervention Toolkit — Aging and Disability Resource Centers toolkit made to supplement the Care Transition Intervention model

##  Presentations

                    - Care Transitions Intervention for Older Adults — JASA presentation on integrating health care and social services to address the social determinants of health; reduce hospital readmissions; and ensure stable, home-based functioning

##  Resources

                    - Evidence-Based Care Transitions Program  — Information from ACL about Aging and Disability Resource Center programs

## Research

                    - Improving Integration of Malnutrition Care in Care Transitions — Information from the Academy of Nutrition and Dietetics about a national dialogue and pilot studies

*Last modified on 12/22/2023*

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ACL funds the Nutrition and Aging Resource Center to build the capacity of senior nutrition programs funded by the Older Americans Act to provide high-quality, person-centered services and enhance program sustainability and resiliency.

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An official website of the Administration for Community Living, an operating division of the U.S. Department of Health and Human Services.