Care Transitions Resource Center

Your rights and how to push back on an unsafe discharge

Step-by-step Medicare appeals process with timelines

85+ item printable checklist for a safe transition

When direct placement is possible and how to arrange it

Special considerations for cognitive impairment

Patient rights, legal limits, and how to appeal a placement decision

How to push back, request a formal review, and protect your loved one

6 care options, emergency planning, and 5-step action plan

Causes, recovery stages, equipment guide, and when to consider a higher level of care

ADL/IADL assessment framework and 7-day caregiver schedule builder

A referral-readiness and facility-comparison workflow when discharge is imminent and home is not safe

What the Medicaid-certified nursing-facility screening framework does—and does not—decide during a referral

A remote adult child’s plan for communication, local support, care-setting questions, transportation, and backup planning

How families can explore long-term nursing-facility transition planning, support needs, and state-program limits

Questions to ask when an existing resident’s return is uncertain, including written policy, records, current needs, and next steps

How to separate a representative role involving resident funds from a personal payment guarantee before signing admission paperwork

Medicare rules, SNF coverage limits, and what families need to know

Coverage options when Medicare rehabilitation ends

Alternative care options when assisted living says no

Medicare rules, extension criteria, and what happens when coverage ends

How SNFs differ from nursing homes, what they provide, and how to choose one

Side-by-side comparison of all four care settings with decision guide

8-stage recovery timeline, home safety checklist, and assisted living decision guide

Complete guide: home readiness, medication management, readmission prevention

15 signs it may be time for a higher level of care

9-domain independent living capacity assessment

Comprehensive comparison across safety, cost, and independence

12-item fall risk scorecard and room-by-room prevention guide

Room-by-room safety assessment with modification guide

Safe medication practices, reconciliation, and management systems

Equipment, power-readiness, overnight planning, and community questions

Treatment-day logistics, transportation, recovery support, and admission fit

Task ownership, outside skilled support, and discharge-plan questions

Daily task ownership, changes in need, and community capability

Seven-day coverage, skilled support, and realistic transition planning

Independence, supplies, dexterity, and care-setting questions

Bedtime routines, cognitive supervision, and overnight responsibility

24-hour coverage, emergency capability, and skilled-task planning

Transfer, equipment, environmental-fit, staffing, and emergency-screening questions

Orientation, accessible routines, daily support, and provider-screening questions

Post-rehab function, transfers, bathroom fit, and changing-care-plan questions

Function, cognition, clinician coordination, and changing medical-complexity questions

Evaluation framework, questions to ask, and red flags to avoid

Communication strategies, sample dialogue, and family meeting guide

13-row comparison table and interactive decision tree

8-week planning timeline, packing lists, and move-in day guide

Room-by-room downsizing plan and family conflict resolution

Direct placement from hospital: when it works and how to arrange it

Warning signs, cost comparison, and building a transition plan

Risk-rated indicators and the conversation guide

Medicare, Medicaid, LTC insurance, VA benefits, and private pay explained

Independent living, assisted living, memory care, and skilled nursing compared

Symptoms, stages, daily care strategies, and family planning

10 indicators and how to have the conversation

Special discharge considerations for cognitive impairment

10-row comparison table and family observation workbook

Causes, triggers, management strategies, and when to seek memory care

When standard assisted living is no longer sufficient

Disease stages, safety indicators, and how to choose between assisted living and memory care

Complete guide to Medicare, Medicaid, private pay, and VA benefits

Aid & Attendance, State Veterans Homes, and eligibility guide

Types, when to establish, and how to avoid common mistakes

What each document does and how to complete them

10-section workbook covering medical, legal, and financial planning

Understanding the difference and when to consider each