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): www.acl.gov/. 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: http://www.aoa.gov/aging_statistics/health_care_reform.aspx#webinar. Webinars on best practices around transitional care, such as working with the Aging Network.
   2. ACL’s Evidence-Based Care Transitions Programs: http://www.acl.gov/Programs/CIP/OCASD/EvidenceBasedCare/index.aspx. Information on evidence-based care transitions programs and further transitional care resources.
2. National Transitions of Care Coalition (NTOCC): www.ntocc.org. 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): www.socialworkers.org/practice/aging/default.asp. 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): http://www.nyam.org/social-work-leadership-institute-v2/care-coordination/n3c/issues-and-actions.html. Resources for  policy makers on best practices for transitional care.
5. Consumers Advancing Patient Safety (CAPS) Transitions Toolkit http://www.consumersadvancingpatientsafety.org/programs/. 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: http://www.cfmc.org/integratingcare/toolkit.htm. 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): http://innovation.cms.gov/initiatives/map/index.html#model=community-based-care-transitions-program. 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.