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Transitions in Care Toolkit

This toolkit was prepared for all professionals who work in health and social service networks. The goal is to help practitioners and clinicians in acute and community settings who make decisions for creating safe transitions for older adults back into or within the community. Care transitions are particularly important when an older adult has experienced an acute health event and receives care in the hospital setting.  When possible, maintaining older adults in their homes and communities is an important goal for quality of life.   

This toolkit provides links to a broad array of assessment tools and examples of model programs that may be helpful in making informed decisions about whether an older adult can transition back into the community safely.   These tools were selected by experienced health care providers from those with an existing evidence base or considered a “best practice” in the care of older adults. This toolkit addresses: care transitions or facilitating return into the community for older adults, the home environment, informal supports & caregiving, neighborhood and community factors, and service systems.  Be sure to look at the care transitions section for the This is a website where after entering information, you can find services for which the older adult is eligible in any area.  You could print a copy for families.  If you are interested in innovative model programs look in the Service Systems section.     

These tools may be useful to help systematically evaluate and plan how older adults can return to the community with the necessary supports in place, so that they (or their families) can successfully care for themselves.  With the increasing number and diversity within the older population, there is a great need to support health and social service providers with complex and sometimes challenging decisions about care.  When possible, facilitating return into one's own home and community may be the most desirable plan after a hospitalization or change in health status.  Careful consideration of the community based and home care options are critical so nursing homes or other longer term based care is not the first choice or only choice for older adults. 

**If you have any comments regarding the toolkit or any difficulty with accessing the links please send a message to

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The information provided using this Web site is only intended to be educational information for health and social service professionals. This toolkit provides links to select information (documents, videos, podcast, etc.) located on external Web sites maintained by various organizations. Once you access information that links you to an external Web site, you are subject to the privacy policy of the Web site containing that information. The links to external Web sites are provided as a service to our users and does not imply endorsement by the Atlanta Regional Geriatric Education Center (ARGEC). Although ARGEC is not responsible for the availability or content of these organizations’ sites, ARGEC does review the sites to assist users in finding the most accurate, reliable and evidence based information.

Permission to copy and distribute documents, files, and other information for non-commercial use needs to be obtained from the original source as indicated on the source document, file, or organization's home page. ARGEC assumes no responsibility for the use of the information provided.