Transitions Across Settings & Providers Work Group

Strengthen partnership and collaboration

Objective:  Strengthening hospital partnerships with CCNC and discovering other opportunities for collaboration to improve transitions, divert unnecessary hospital and emergency department use, and integrate home- and community-based options.

Work Group Co-leads: Sabrena Lea (DAAS), Trish Farnham (DMA)

  • Strengthen hospitals partnerships with CCNC and engage hospitalists and discharge planners in transitional care
  • Leverage and align efforts with other CMS funded transition and diversion initiatives
  • Coordinate efforts with and incorporate lessons learned from the Patient-centered Discharge Project Grant and related transition initiatives underway in NC
  • Integrate Money Follows the Person and transitions across settings & providers including nursing homes, adult care homes, and hospice, and integrate home and community-based options.
  • Explore community linkage and support bundling practices in other states
  • Align efforts with CCNC’s transitional care program and enhance efforts across provider settings

Next Meeting and Location
Work group meetings have been completed. 


  • Transitions from Acute Care to Community
  • Transitions from Nursing Home to Other Long Term Settings and Transitions Among Providers 
Meeting Notes