UPAAA plans a Care Transition Coordination and Support service using community health workers (CHWs) to assist adults 60+ being discharged from hospitals and medical facilities back to their preferred residence. The program will establish referral procedures with local hospitals and critical care facilities, develop assessment protocols and care plan guidelines aligned with ACLS Bureau standards, and record data in WellSky/NAPIS, with weekly or bi-weekly follow-ups to prevent readmissions and decline. The service is budgeted at $5,555 in FY 2027 federal/state dollars but is positioned as a planning-period initiative that will require workflows with multiple hospitals and care providers.This creates an opportunity for vendors offering care management platforms, CHW training, integration with hospital EHRs, and analytics on readmissions and service utilization, particularly those with experience in transitional care and senior services.

The program will rely on CHWs and coordination with regional hospitals, but no specific hospital systems or IT vendors are named, leaving technology and process design open.