Community-based Care Transitions Program

The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program.

The CCTP Partners

Select anywhere on the map below to view the interactive version CCTP Mapped

There are 72 participating sites involved in the Community-based Care Transitions Program. (List)
To view an interactive map of this Model, visit the Where Innovation is Happening page.


View all CCTP site summaries.


Round 1: The following partner organizations were announced on November 18, 2011:

  • Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio)
  • Atlanta Community-Based Care Transitions Program (Atlanta CCTP) (Georgia)
  • Council for Jewish Elderly (“CJE SeniorLife”) in Chicago, IL (Illinois)
  • Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona)
  • Elder Services of the Merrimack Valley, Inc. (Massachusetts & New Hampshire)
  • The Southern Maine Agency on Aging/Aging and Disability Resource Center (SMAA/ADRC) (Maine)
  • The Southwest Ohio Community Care Transitions Collaborative (Ohio)

Round 2: The following partner organizations were announced on March 14, 2012:

  • Carondelet Chronic Care Navigation Program (Arizona)
  • Elder Services of Worcester, Massachusetts (Massachusetts)
  • El Paso, Texas Aging and Disability Resource Center (Texas)
  • Lifespan of Greater Rochester Inc. (New York)
  • North Philadelphia Safety Net Partnership (Pennsylvania)
  • Ohio AAA Region 8 (Ohio)
  • St. John Providence Health System (Michigan)
  • Senior Alliance, Area Agency on Aging 1-C (Michigan)
  • Western Pennsylvania Community Care Transition Program (Pennsylvania)

Round 3: The following partner organizations were announced on August 17, 2012:

  • Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania)
  • Catholic Charities of the Archdiocese of Chicago (Illinois)
  • Elder Options (Florida)
  • Greater Miami Coalition to Prevent Unnecessary Rehospitalizations (Florida)
  • Los Angeles Mid-City Integrated Care Collaborative (California)
  • Lower Rio Grande Valley Development Council (Texas)
  • Mt. Sinai Hospital (New York)
  • Northwest Triad Care Transitions Community Program (NTCTCP) (North Carolina)
  • San Francisco Transitional Care Program (SFTCP) (California)
  • Somerville-Cambridge Elder Services (Massachusetts)
  • Whatcom Alliance for Healthcare Access (Washington)

Round 4: The following partner organizations were announced on January 15, 2013:

  • Access East Community-based Transitional Partnership (North Carolina)
  • AccessCare (North Carolina)
  • Aging & In-Home Services of Northeast Indiana (Indiana)
  • Aging and Long Term Care of Eastern Washington (Washington)
  • AltaMed Health Services Corporation (California)
  • Appalachian Community Transitions (ACTion) Project (Virginia)
  • Catholic Health Care Transitions Services, Inc. (Florida)
  • Central Savannah River Area Regional Commission (Georgia)
  • Central Texas Aging and Disability Resource Center (Texas)
  • Chattanooga Regional Medicare Community-based Care Transitions Program (Tennessee)
  • Community Research Resource Information Services for Seniors, Inc. (CHRIS) (Illinois)
  • The Coordinating Center (Maryland)
  • Denver Regional Council of Governments (Colorado)
  • East Central Ohio Community Care Transitions Coalition (Ohio)
  • Eastern Virginia Care Transitions Partnership (Virginia)
  • Glendale Memorial Hospital and Health Center (California)
  • Kansas City Quality Improvement Consortium, Inc. (Missouri)
  • Maui County Office on Aging (Hawaii)
  • Missoula Aging Services (Montana)
  • Multnomah County Aging and Disability Services (Oregon)
  • Northeast Georgia Regional Commission (Georgia)
  • Partners in Care Foundation (California)
  • Queens Care Transition Collaborative (New York)
  • San Diego Care Transitions Partnership (California)
  • Siouxland Care Transitions (Iowa)
  • Southern Alabama Regional Council on Aging (SARCOA) (Alabama)
  • Three Rivers Planning & Development District (Mississippi)
  • Tri-County Aging Consortium (Michigan)
  • Upstate Care Transitions Coalition (South Carolina)
  • West Central Florida Area Agency on Aging (Florida)

Round 5: The following partner organizations were announced on March 07, 2013:

  • Area Office on Aging of Northwestern Ohio, Inc. (Ohio)
  • Brewster Place (Kansas)
  • Capital Area Agency on Aging (CAAA) (Louisiana)
  • Central New Jersey Care Transition Program (New Jersey)
  • Community SeniorServ (California)
  • Deep East Texas Council of Governments (DETOG) Area Agency on Aging (AAA) (Texas)
  • Dominican Sisters Family Health Service, Inc. (New York)
  • Green River Area Development District (Kentucky)
  • Jewish Home for the Aging Geriatric Services Inc. (California)
  • Kentucky Appalachian Transitions Services (Kentucky)
  • LifeSpan Resources, Inc. (Indiana)
  • Sun Health (Arizona)
  • Top of Alabama Regional Council of Governments (Alabama)
  • Valley Area Agency on Aging (Michigan)
  • York County Area Agency on Aging (Pennsylvania)


Care transitions occur when a patient moves from one health care provider or setting to another. Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year. Hospitals have traditionally served as the focal point of efforts to reduce readmissions by focusing on those components that they are directly responsible for, including the quality of care during the hospitalization and the discharge planning process. However, it is clear that there are multiple factors along the care continuum that impact readmissions, and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions.

The CCTP seeks to correct these deficiencies by encouraging a community to come together and work together to improve quality, reduce cost, and improve patient experience.

The CCTP is part of the Partnership for Patients, a nationwide public-private partnership that aims to reduce preventable errors in hospitals by 40 percent and reduce hospital readmissions by 20 percent.

Initiative Details

The CCTP, launched in February 2012, will run for 5 years. Participants will be awarded two-year agreements that may be extended annually through the duration of the program based on performance.

Community-based organizations (CBOs) will use care transition services to effectively manage Medicare patients' transitions and improve their quality of care. Up to $300 million in total funding is available for 2011 through 2015. The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level. CBOs will only be paid once per eligible discharge in a 180-day period for any given beneficiary.


CCTP is currently at capacity and no longer accepting applications. There are no plans for future sites to be added to the program.

CBOs, or acute care hospitals that partner with CBOs, were eligible to submit an application describing the proposed care transition intervention(s) for Medicare beneficiaries in their communities who are at high risk of readmission. Interested CBOs must have provided care transition services across the continuum of care and have formal relationships with acute care hospitals and other providers along the continuum of care.

An interested CBO must have been physically located in the community it proposed to serve, must have been a legal entity that could accept payment for services, and must have had a governing body with representation from multiple healthcare stakeholders including consumers. In selecting CBOs, preference was given to Administration on Aging (AoA) grantees that provided care transition interventions in conjunction with multiple hospitals and practitioners and/or entities that provided services to medically-underserved populations, small communities, and rural areas.

Additional Information

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