CCTP Site Summaries

 

There are currently 102 partners of the Community-based Care Transitions Program (CCTP) announced in three rounds. View only: Round 1 | Round 2 | Round 3 | Round 4  | Round 5

The following are site summaries for all CCTP partners:

Alabama

Southern Alabama Regional Council on Aging (SARCOA)
The Southern Alabama Regional Council on Aging (SARCOA), in partnership with 8 regional hospitals, will serve Medicare beneficiaries in a 7-county region of southern Alabama. The Area Agency on Aging will lead the partnership that aims to deliver care transition services to Medicare beneficiaries living in rural counties designated as Health Professional Shortage Areas. The 8 hospitals include Southeast Alabama Medical Center, Flowers Hospital, Medical Center Barbour, Dale Medical Center, Wiregrass Medical Center, Medical Center Enterprise, Mizell Memorial Hospital, and Andalusia Regional Hospital.

Top of Alabama Regional Council of Governments
Top of Alabama Regional Council of Governments in Huntsville, the designated local Area Agency on Aging, will partner with Huntsville Hospital, Highlands Medical Center, Athens-Limestone Hospital, and Crestwood Medical Center to deliver the Care Transitions Intervention to residents of Jackson, Limestone, and Madison Counties in northeast Alabama. The community-based organization will coordinate services across its partner hospitals and downstream providers for Medicare beneficiaries living in rural, urban, and mountainous areas.

Arizona

Carondelet Chronic Care Navigation Program
It will work to improve care transitions among high-readmission populations throughout southern Arizona. Carondelet St. Joseph’s Hospital will lead the effort, partnering with two additional Carondelet Health Network providers, Carondelet St. Mary’s and the Carondelet Heart & Vascular Institute, in cooperation with the Pima Council on Aging and the University of Arizona’s Center on Aging.
Carondelet Chronic Care Navigation Detailed Summary (PDF)

Maricopa County, Arizona: The Area Agency on Aging, Region One
Serving Maricopa County in Arizona, in partnership with John C. Lincoln North Mountain Hospital, West Valley Hospital, Scottsdale Healthcare Osborn Medical Center, John C. Lincoln Deer Valley Hospital; APIPA, a Medicaid Acute Care Plan that serves dually-enrolled Medicare fee-for-service beneficiaries; and Sunwest Pharmacy.
Maricopa County, Arizona Detailed Summary (PDF)

Sun Health
Sun Health in partnership with Banner Boswell and Del E. Webb Medical Centers, and two nonprofit skilled nursing/rehabilitation facilities will provide care transition services to high risk Medicare beneficiaries residing in the Northwest area of Maricopa County, Arizona. Through the Community-based Care Transitions Program, Sun Health will expand its Sun Health Care Transitions pilot program to serve approximately 1,800 beneficiaries per year using a model that includes an in-home assessment, medication reconciliation, home safety evaluation, fall risk assessment, and mini depression screening across fourteen zip codes encompassing some rural and medically underserved areas.

Arkansas

CareLink
A Central Arkansas Area Agency on Aging (AAA), it will partner with the University of Arkansas for Medical Sciences Academic Medical Center, a high readmission hospital, St. Vincent Hospital, and two Federally Qualified Health Centers, Jefferson Comprehensive Care System and ARcare. They will provide services for Medicare beneficiaries across five Central Arkansas counties including medically underserved populations and both urban and rural areas.
CareLink Detailed Summary (PDF)

California

Advanced Care Transitions (ACT), Marin County, California
This is a partnership between California’s Marin County Health & Human Service Agency, Division of Aging and Adult Services, and two hospitals: Marin General Hospital and Novato Community Hospital. It will provide transitional care services to significantly reduce hospital readmissions among Medicare beneficiaries. ACT will reach at-risk populations along both the County’s north-south urban corridor and rural west.
Advanced care Transitions of Marin County, California Detailed Summary (PDF)

AltaMed Health Services Corporation
AltaMed Health Services Corporation, located in Los Angeles, California, will serve a predominantly low-income medically-underserved population living in the Metropolitan and East Los Angeles urban catchment areas. In collaboration with Hollywood Presbyterian Medical Center, White Memorial Medical Center, Citrus Valley Medical Center and Foothill Presbyterian Hospital and leveraging a regional public-private collaborative consisting of county hospital and the nation’s largest Federally Qualified Health Center (FQHC) with an Independent Practice Association (IPA) in Los Angeles County, AltaMed builds on its long history of serving ethnically diverse and low-income Medicare beneficiaries in Los Angeles County.

Community SeniorServ
Community SeniorServ and four local hospital health systems have joined to create Southern California’s Orange County Care Transitions Partnership. Addressing a multicultural, low-income beneficiary population, the program also includes a network of skilled nursing facilities, and a coalition of adult day health services, Meals on Wheels and the Office on Aging, among others. Hospital partners include, Western Medical Center – Santa Ana, AHMC Anaheim Regional Medical Center, the University of California Irvine Medical Center, and St. Jude Medical Center.

Glendale Memorial Hospital and Health Center
Glendale Memorial Hospital and Health Center, as the lead applicant in partnership with Partners in Care Foundation, and two additional hospitals, Glendale Adventist Medical Center and Verdugo Hills Hospital, will serve high-risk Medicare beneficiaries residing in the Los Angeles Counties of Glendale, Burbank, and La Canada-Flintridge. The collaborative will aim to redesign the patient experience and discharge planning process for patients at-risk of readmission in a culturally diverse community of Los Angeles.

Jewish Home for the Aging Geriatric Services Inc.
Jewish Home for the Aging Geriatric Services Inc., a community-based organization located in the heart of the San Fernando Valley in partnership with three area hospitals, the Los Angeles Department on Aging, and multiple senior centers, has formed the San Fernando Valley Transitions Coalition (SFVTC). The SFVTC will provide care transition services to an ethnically diverse high-risk Medicare population spanning both federally-designated medically- underserved areas and health professional shortage areas. Over 1,000 beneficiaries will be served each year. Hospital partners include Mission Community Hospital, Providence Tarzana Medical Center, and Valley Presbyterian Hospital.

Los Angeles Mid-City Integrated Care Collaborative
The Los Angeles Mid-City Integrated Care Collaborative, operated by Jewish Family Service of Los Angeles, will address the problem of high readmission rates throughout the city’s especially multicultural and densely-populated districts by drawing on an extensive network of skilled nursing facilities, rehabilitation centers, and community-based organizations. Partnering facilities include Good Samaritan Hospital, St. Vincent Medical Center, and Olympia Medical Center.

Partners in Care Foundation
Partners in Care Foundation, a community-based organization, will primarily serve Medicare beneficiaries located in Los Angeles County. Using a combination of the Bridge Model of Transitional Care and the Care Transitions Intervention, the organization seamlessly work across 3 hospitals that include Ronald Reagan UCLA Medical Center, Santa Monica UCLA Medical Center and St. John’s Health Center serving a predominantly low-income and ethnically, diverse population. The partnership further expands across the community by leveraging local nonprofit, human service and aging organizations to redesign care across the continuum in Los Angeles.

San Diego Care Transitions Partnership
San Diego Care Transitions Partnership spearheaded by Aging and Independence Services, the Area Agency on Aging and Aging and Disability Resource Centers of San Diego County in partnership with the four largest health systems in San Diego including Scripps Health, Sharp Healthcare, Palomar Health and the University of California San Diego Health System will provide one or more care transition services customized to meet the needs of high risk Medicare beneficiaries residing in San Diego County. Services may include the Care Transition Intervention ®, enhanced supportive services, nurse navigators or pharmacist intervention. Across the four hospital systems a total of 11 hospitals are represented. This community builds on its experience as a Beacon Community and as a recipient of multiple Administration for Community Living grants for care transitions services.

San Francisco Transitional Care Program (SFTCP)
The San Francisco Transitional Care Program (SFTCP) will expand on the hospital-to-home transitional care model to include eight hospitals and nine additional community-based organizations in San Francisco County. The program will leverage a wide range of community supports to facilitate the continuum of care for an estimated 5,000 Medicare beneficiaries. Participating hospitals include the California Pacific Medical Center (Pacific, St. Luke’s and Davies Campuses), St. Francis Memorial Hospital, St. Mary’s Medical Center, San Francisco General Hospital, Chinese Hospital, and UCSF Medical Center.

Sonoma County Area Agency on Aging
Located north of San Francisco, Sonoma County Area Agency on Aging, in partnership with the Sonoma County Department of Health Services, will lead a diverse coalition of health care providers to serve high-risk Medicare beneficiaries living in Sonoma County. Screening instruments including the LACE index risk prediction model and  Better Outcomes for Older adults through Safe Transitions screening tools will be used by hospitals to identify high risk patients and subsequently link them up to Care Transitions Intervention coaches across Santa Rosa Memorial Hospital, Petaluma Valley Hospital, Palm Drive Hospital, Sutter Medical Center of Santa Rosa, and Sonoma Valley Hospital. Other critical partners include Kaiser Foundation Hospital – Santa Rosa, Healdsburg District Hospital, Council on Aging, Petaluma People Services Center, and West County Community Services.

Ventura County Area Agency on Aging
Ventura County Area Agency on Aging will lead a partnership with the Camarillo Health Care District and five hospitals that include Community Memorial Hospital San Buenaventura, St. John’s Regional Medical Center, St. John’s Pleasant Valley Hospital, Simi Valley Hospital & Health Care Services, and Ventura County Medical Center. Based on Ventura’s success piloting care transition intervention across a number of its hospital partners, the program will serve diverse Medicare beneficiaries by providing culturally sensitive transitional care services.

Colorado

Denver Regional Council of Governments
As the designated Area Agency on Aging in the Denver metropolitan area, the Denver Regional Council of Governments (DRCOG) will serve Medicare beneficiaries living in eight counties. A number of patients reside in Medically Underserved Area/Population. The expansive community partnership works across the care continuum leveraging two health systems and multiple downstream providers such as skilled nursing facilities, home health agencies, and various non-profit entities. The hospitals include Exempla Saint Joseph Hospital, Medical Center of Aurora, Sky Ridge Medical Center, Swedish Medical Center, Presbyterian/St Luke's Medical Center, North Suburban Medical Center and Rose Medical Center.

Upper Arkansas Area Council of Governments
Upper Arkansas Area Council of Governments, an Area Agency on Aging located in Canon City, Colorado, will lead an expansive partnership delivering the Care Transitions Intervention to Medicare beneficiaries in El Paso, Pueblo, Fremont, Chaffee, Custer, Lake, and Teller counties. Many of these beneficiaries reside in medically-underserved and rural areas, and small communities. Providers across the care continuum include acute care hospitals (Centura Health-Penrose St. Francis Health Services, Memorial Hospital Central, Centura Health – St. Mary Corwin Medical Center, Parkview Medical Center and Centura Health - St. Thomas More Hospital), critical access hospitals (St. Vincent Hospital General District, Pikes Peak Regional Hospital, and Heart of the Rockies Regional Medical Center), a Federally-Qualified Health Center (Peak Vista Community Health Center) along with the Pueblo Area Agency on Aging and Pikes Peak Area Council of Governments Area Agency on Aging.

Connecticut

Connecticut Community Care, Inc. (CCCI)
Connecticut Community Care, Inc. (CCCI), a community-based organization, will partner with nine hospitals to provide care transition services in North Central and Eastern Connecticut (Hartford, Tolland, Windham, and New London counties). CCCI will build upon its strong community relationships with hospitals, post acute care, and community organizations to deliver the care transition services to over 9,000 Medicare fee-for-service beneficiaries annually. The hospitals include: St. Francis Hospital and Medical Center, John Dempsey Hospital, Bristol Hospital, Hartford Hospital, Hospital of Central Connecticut, Midstate Medical Center, Windham Community Memorial Hospital and Hatch Hospital, Lawrence and Memorial Hospital, and William Backus Hospital.

Greater New Haven Coalition for Safe Transitions
This is a partnership between the Yale-New Haven Hospital, a high readmission hospital, and the AAA of South Central Connecticut and the Hospital of Saint Raphael in New Haven, will provide care transition services to a diverse population in the New Haven metropolitan area some of which has been designated as medically-underserved by the Health Resources and Services Administration (HRSA).
Greater New Haven Coalition for Safe Transitions Detailed Summary (PDF)

Florida

Catholic Health Care Transitions Services, Inc.
Catholic Health Care Transitions Services, Inc., located in Lauderdale Lakes, will lead a broad-based community collaborative serving Medicare beneficiaries in portions of Miami-Dade and Broward counties in Southeast Florida. In partnership with North Shore Medical Center, Hialeah Hospital, Palmetto General Hospital, and Holy Cross Hospital along with home health agencies, skilled nursing facilities and human services organization across the care continuum, the coalition targets a culturally diverse, low-income and medically underserved population of the state.

Oceola-St. Cloud Community-based Care Transitions Coalition
Oceola-St. Cloud Community-based Care Transitions Coalition is a partnership of the Senior Resource Alliance, the AAA and ADRC for the Orlando region, Osceola Regional Medical Center, St. Cloud Regional Medical Center, and several skilled nursing facilities. The coalition will provide care transition services to high risk Medicare beneficiaries.

Greater Miami Coalition to Prevent Unnecessary Rehospitalizations
The Greater Miami Coalition to Prevent Unnecessary Rehospitalizations is led by the Miami-Dade County Alliance for Aging and is partnering with seven hospitals and several community home health and social service providers to provide care transition services to Medicare beneficiaries in South Florida. Hospital partners include Baptist Hospital of Miami, Doctors Hospital, Jackson Memorial Hospital, Larkin Community Hospital, Mount Sinai Medical Center, South Miami Hospital, and University of Miami Hospital.

Elder Options
Elder Options will serve low-income, rural, and medically underserved populations across 55 zip codes and 13 counties in North Central Florida. The Mid-Florida Area Agency on Aging will work with two acute care hospitals – (Shands Hospital at the University of Florida and the North Florida Regional Medical Center) as well as local providers including home health agencies, skilled nursing facilities, and the University of Florida’s College of Nursing.

West Central Florida Area Agency on Aging
The West Central Florida Area Agency on Aging, Inc. in partnership with eight acute care hospitals, three skilled nursing facilities, and three home health providers will deliver the Care Transitions Intervention® in conjunction with elements of Project RED and BOOST to over 2000 high risk Medicare beneficiaries residing in sixty-four zip codes spanning both rural and urban areas. Hospital partners include: University Hospital at Tampa, University Hospital at Carrollwood, Memorial Hospital of Tampa, Saint Joseph’s Hospital, South Bay Hospital, South Florida Baptist Hospital, Tampa General Hospital, and Town & Country Hospital.

Georgia

Atlanta Community-Based Care Transitions Program (Atlanta CCTP)
A collaborative partnership serving ten counties in the Atlanta region, including the Atlanta Regional Commission (an Area Agency on Aging), and six urban area hospitals: Emory University Hospital Midtown, Gwinnett Medical Center, Piedmont Hospital, Southern Regional Hospital, WellStar Cobb Hospital and WellStar Kennestone Hospital.
Atlanta CCTP Detailed Summary (PDF)

Central Savannah River Area Regional Commission
The Central Savannah River Area Regional Commission, an area agency on aging, will partner with three acute care hospitals to provide the Care Transitions Intervention® along with a tailored post-discharge support package to approximately 1,000 high-risk Medicare beneficiaries across fourteen counties in east central Georgia. Partner hospitals include Jefferson Hospital, University Hospital Augusta, and, University Hospital McDuffie. 

Northeast Georgia Regional Commission
The Northeast Georgia Regional Commission’s Area Agency on Aging in partnership with four acute care hospitals will deliver the Care Transitions Intervention® along with a supportive service package to high risk Medicare beneficiaries. This community spans twelve counties and represents both rural and medically underserved populations. Hospital partners include Athens Regional Medical Center, Barrow Regional Medical Center, Newton Medical Center, and Walton Regional Medical Center.

Hawaii

Maui County Office on Aging
The Maui Community Partnership (MCP), led by the Maui County Office on Aging (MCOA), will expand ongoing transitions efforts to reduce Medicare hospital readmissions using the Care Transitions Intervention (CTI) Model. The program will serve eligible beneficiaries from Maui’s primary hospital, Maui Memorial Medical Center (MMMC). Maui County has unique geographic and cultural challenges, including that of providing support to individuals on three different islands.

Illinois

AgeOptions
As the AAA and Aging and Disability Resource Center (ADRC) in Cook County, Illinois, it will partner with the Chicago, suburban Cook County, and southern Illinois Bridge Coordinating Agencies to provide care transition services at six hospitals. The Bridge Coordinating Agencies include Aging Care Connections, Kenneth Young Center, North Shore Senior Center, PLOWS Council on Aging, Rush University Older Adult Program, and Solutions for Care. The hospital network includes Adventist LaGrange Memorial Hospital, St. Alexius Medical Center, Advocate Lutheran General, Palos Hospital, Rush University Medical Center, and MacNeal Hospital.
AgeOptions Detailed Summary (PDF)

Catholic Charities of the Archdiocese of Chicago
Catholic Charities of the Archdiocese of Chicago, a community-based organization, will partner with four hospitals to provide care transition services in Southern Cook County of Illinois. Catholic Charities will serve 8,700 Medicare fee-for-service beneficiaries annually.  The hospitals include: Ingalls Memorial Hospital, MetroSouth Medical Center, Franciscan St. James Health, and Little Company of Mary Hospital.

Community Research Resource Information Services for Seniors, Inc. (CHRIS)
The Community Research Resource Information Services for Seniors, Inc. (CHRIS) is partnering with three local hospitals to provide care transition services across Illinois’ Champaign and Vermillion Counties. CHRIS will use the Bridge Model with coalition partners who include the East Central Illinois Area Agency on Aging, University of Illinois Center on Health Aging and Disability, social service providers, and a range of related stakeholders. CHRIS partner hospitals include: Carle Foundation Hospital, Provena Covenant Medical Center - Urbana, and Provena United Samaritans Medical Center – Logan.

Council for Jewish Elderly (“CJE SeniorLife”) in Chicago, IL
Partnering with Northwestern Memorial, Saint Joseph Hospital, and Saint Francis Hospital and working closely with Area Agencies on Aging in Chicago and suburbs, local Care Coordination Units (CCUs), and Illinois’ Quality Improvement Organization, IFMC.
CJE SeniorLife Detailed Summary (PDF)

Indiana

Aging & In-Home Services of Northeast Indiana
Aging & In-Home Services of Northeast Indiana, Inc. (AIHS), a designated Area Agency on Aging (AAA) and Aging & Disability Resource Center (ADRC) has partnered with LifeStream Services, Inc., a AAA based in the adjacent planning and service area, to provide care transition services for high-risk Medicare beneficiaries. This dual AAA partnership brings together 11 acute care hospitals from seven separate health systems in Eastern Indiana. Each of the participating hospitals has also been working within their own health systems, to reduce their rates of unnecessary readmissions. Partner hospitals include: Henry County Memorial Hospital, DeKalb Memorial Hospital, Bluffton Regional Medical Center, St. John’s Hospital, the Community Hospital of Anderson, IU Health Ball Memorial Hospital, Parkview Huntington Hospital, Parkview Whitley Hospital, Parkview Noble Hospital, Parkview Randallia Hospital, and Parkview Regional Hospital.

LifeSpan Resources, Inc.
LifeSpan Resources, Inc., an Area Agency on Aging and Aging and Disability Resource Center located in New Albany, Indiana, will lead a community coalition serving Medicare beneficiaries across Clark, Floyd, Harrison, and Scott Counties in the southern part of the state. In partnership with Clark Memorial Hospital and Floyd Memorial Hospital and Health Services, LifeSpan Resources aims to deliver integrated and seamless care for beneficiaries using the Care Transitions Intervention. The service region includes rural and medically-underserved areas.

Iowa

Siouxland Care Transitions
Siouxland Care Transitions, spearheaded by Siouxland Aging Services, an Area Agency on Aging, located in Sioux City, Iowa will partner with two acute care hospitals, the Siouxland Community Health Center, and the Winnebago Tribe of Nebraska to provide care transition services to over 1500 high risk Medicare beneficiaries including Native Americans. This community spans three states and encompasses rural and medically underserved areas.

Kansas

Brewster Place
Topeka, Kansas’ Congregational Home DBA Brewster Place will lead the Capital Care Transitions Coalition with strong support from two Area Agencies on Aging and the Kansas Department on Aging. The coalition will partner with the two acute care hospitals in the area, Stormont-Vail HealthCare and St. Francis Health Center, to prevent avoidable hospital admissions using the Care Transitions Intervention combined with in-home monitoring and telehealth services across a seven county demographically diverse area in Northeast Kansas. Coalition membership includes representation from the Northeast Kansas Area Agency on Aging, Jayhawk Area Agency on Aging, Holton Community Hospital (a critical access hospital), Shawnee County Health Agency, Visiting Nurses Association, Washburn University School of Nursing, and Brewster at Home. The project will serve medically underserved areas of Shawnee County, Kansas as well as Medically Underserved Populations in neighboring communities.

Kentucky

Green River Area Development District
The Green River Area Development District, located in Owensboro, Kentucky will lead a coalition consisting of two hospitals (Owensboro Medical Health System and Methodist Hospital) in a largely rural area spanning across seven counties in the western part of the state. Health Care Excel, the local Medicare Quality Improvement Organization, will support the coalition as it aims to coordinate care across the continuum using a combination of services including the Care Transitions Intervention, telehealth, and tailored supportive services.

Kentucky Appalachian Transitions Services
Kentucky Appalachian Transitions Services and its community coalition will serve residents living in counties across Kentucky and West Virginia. Four hospitals within the Appalachian Regional Healthcare system are included in the 21-county multi-state collaboration across the mountainous, rural communities of Southeastern Kentucky and Southern West Virginia (Hazard ARH Regional Medical Center, Harlan Appalachian Regional Healthcare Hospital, Whitesburg ARH Hospital, and Williamson ARH Hospital). The coalition also includes Kentucky River Area Agency on Aging, Cumberland Valley Area Agency on Aging, Kentucky Medicare Quality Improvement Organization and over 40 downstream providers and community key stakeholders. The organization will build on its current private sector care transition pilot using the Transitional Care Model.

Louisiana

Capital Area Agency on Aging (CAAA)
Baton Rouge’s Capital Area Agency on Aging (CAAA) will target at-risk Medicare beneficiaries throughout five southeast Louisiana parishes. Serving the state’s rural populations for over 30 years, CAAA will partner with high-readmission hospitals in a targeted approach involving coaching, supplemental supports, and transportation services. Participating facilities include St. Tammany Parish Hospital, Slidell Memorial Hospital, North Oaks Medical Center, and Lakeview Regional Medical Hospital.

Maine

The Southern Maine Agency on Aging/Aging and Disability Resource Center (SMAA/ADRC)
Serving five counties in southern and mid-coast Maine in partnership with the Maine Medical Center Physician-Hospital Organization and five MaineHealth hospitals: Southern Maine Medical Center, Maine Medical Center, Mid-Coast Hospital, Miles Hospital, and PenBay Medical Center.
SMAA/ADRC Detailed Summary (PDF)

Maryland

The Coordinating Center
The Coordinating Center, located in Millersville, Maryland, in collaboration with Bon Secours Hospital, Maryland General Hospital, and University of Maryland Medical Center and Baltimore City Aging & Disability Resource Center will implement a comprehensive care transition program using the Care Transitions Intervention (CTI)®. The community coalition will coordinate care across the continuum for patients primarily living in West Baltimore, a medically underserved region of the city. The organization has extensive experience in providing care transition services to ethnically and socially diverse communities throughout the state.

Massachusetts

Elder Services of Berkshire County
A Massachusetts-designated Aging Services Access Point (ASAP) and federally-designated AAA in rural western Massachusetts, it will partner with Berkshire Medical Center and the Berkshire Visiting Nurse Association to improve care transition services for Medicare beneficiaries. The program will rely on collaboration among the clinical and administrative leaders and build upon efforts underway to improve care intervention across the community in Berkshire County.
Elder Services of Berkshire County Detailed Summary (PDF)

Elder Services of Worcester, Massachusetts
A Massachusetts-designated Aging Services Access Point (ASAP) and federally-designated AAA, it will partner with Bay Path Elder Services. They will provide care transitions services in partnership with seven hospitals extending from rural western Massachusetts counties to the MetroWest region between Boston and Worcester. Hospitals from both UMass Memorial and Vanguard systems include: MetroWest Medical Center; St. Vincent Hospital; UMass Memorial Medical Center; Wing Memorial Hospital; Marlborough Hospital; Clinton Hospital, and HealthAlliance Hospital.
Elder Services of Worcester, Massachusetts Detailed Summary (PDF)

Somerville-Cambridge Elder Services
Somerville-Cambridge Elder Services, a Massachusetts-designated Aging Services Access Point (ASAP) and an Area Agency on Aging (AAA), is partnering with Mystic Valley Elder Services, two large integrated hospital networks (Cambridge Health Alliance and Hallmark Health System) and dozens of community-based health and social service providers to provide care transitions services to high-risk Medicare beneficiaries throughout Middlesex County, Massachusetts.

Massachusetts/New Hampshire

Elder Services of the Merrimack Valley, Inc.
The Elder Services of the Merrimack Valley, Inc., in partnership with Anna Jacques Hospital, Saints Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital, provides care transitions services to Medicare beneficiaries who are at increased risk for readmission residing in 23 cities/towns in the Merrimack Valley of Massachusetts and ten bordering cities/towns in southern New Hampshire.
Merrimack Valley of Massachusetts and Southern New Hampshire (PDF)

Michigan

Michigan Area Agency on Aging 1-B
In partnership with southeast Michigan hospitals William Beaumont-Troy, Henry Ford Health System Macomb, Henry Ford Health System Macomb-Warren Campus and Pontiac Osteopathic Hospital; nursing homes; skilled home care agencies, and hospice agencies, it will target Medicare fee-for-service beneficiaries in the designated medically underserved areas in Oakland and Macomb counties, Michigan. This coverage area includes a diverse range of populations in the greater Detroit area, ranging from urban to sparsely populated northern communities.
Michigan Area Agency on Aging Detailed Summary (PDF)

St. John Providence Health System
Located in Warren, Michigan, it will partner with Adult Well Being Services to deliver care intervention to Medicare beneficiaries in Detroit (Wayne County), and Macomb and Southern Oakland Counties. The hospital partnership includes St. John Hospital and Medical Center, Providence Hospital and Medical Center, and St. John Macomb-Oakland Hospital. The care transition services will serve beneficiaries who predominantly reside in an urban area.
St. John Providence Health System Detailed Summary (PDF)

The Senior Alliance, Area Agency on Aging 1-C
Located in Wayne, Michigan, it will provide care transitions services across 34 communities in southern and western Wayne County. The Senior Alliance will partner with six hospitals that include Garden City Hospital, St. Mary Mercy Hospital, Oakwood Hospital and Medical Center, Oakwood Annapolis Hospital, Oakwood Heritage Hospital, and Oakwood Southshore Medical Center.
The Senior Alliance Detailed Summary (PDF)

Tri-County Aging Consortium
The Tri-County Aging Consortium (or Tri-County Office on Aging) has partnered with two regional hospitals, Edward W Sparrow Hospital and Ingham Regional Medical Center, and the Chronic Disease Management Collaborative to serve Medicare beneficiaries residing in Clinton, Eaton, and Ingham counties in mid-Michigan (including cities of Lansing and East Lansing). The primary interventions use Project BOOST and the Bridge Model of Transitional Care. The tri-county partnership leverages its prior cooperative structure dating back to 2008.

Valley Area Agency on Aging
Flint Michigan’s Valley Area Agency on Aging will coordinate and lead the area’s Transforming Transitions Project across central Michigan. Tailored to the area’s unique demographics, the Project will implement a modified Better Outcomes for Older adults through Safe Transitions across all partnering hospitals. Building off successful prior transitions experience, the Project will include Hurley Medical Center, McLaren-Flint, Genesys Regional Medical Center, Owosso Memorial Hospital, and McLaren-Lapeer Region..

Minnesota

The Metropolitan Area Agency on Aging
The Metropolitan Area Agency on Aging will provide care transition efforts within Minneapolis’s urban center and surrounding neighborhoods of Hennepin County. Together with Hennepin County Medical Center and North Memorial Hospital, the program expects to reach over 2,600 Medicare beneficiaries annually.

Mississippi

Three Rivers Planning & Development District
Through the Three Rivers Community-based Care Transitions Program, The Three Rivers Planning & Development District Area Agency on Aging in partnership with the Golden Triangle Area Agency on Aging, six acute care hospitals, multiple home health organizations, skilled nursing facilities, and critical access hospitals will deliver the Care Transitions Intervention® to high risk Medicare beneficiaries residing across ten rural and medically underserved areas of northeast Mississippi. Hospital partners include Baptist Memorial Hospital North Mississippi, Clay County Medical, Gilmore Memorial Hospital, North Mississippi Medical, Trace Regional Hospital, and Webster General Hospital.

Missouri and Kansas

Kansas City Quality Improvement Consortium, Inc.
Serving the Greater Kansas City Bi-State area, the Kansas City Quality Improvement Consortium (KCQIC) is a non-profit community coalition providing a forum for collaboration and encouraging best practices in health care. The KCQIC care transitions partnership includes 15 hospitals, Area Agencies on Aging, physicians and a wide range of downstream providers to reduce readmission rates for high-risk Medicare beneficiaries. Partnering in this effort are: Liberty Hospital, North Kansas City Hospital, Lee’s Summit Medical Center, Centerpoint Medical Center, Research Medical Center, Research Belton Hospital, Saint Joseph Medical Center, Saint Mary’s Medical Center, Truman Medical Center – Hospital Hill, Truman Medical Center -Lakewood, Menorah Medical Center, Olathe Medical Center, Overland Park Regional Medical Center, Shawnee Mission Medical Center, and Providence Medical Center.

Montana

Missoula Aging Services
Missoula Aging Services, an Area Agency on Aging for Missoula and Ravalli counties of Montana, and the Aging and Disability Resource Center for Missoula county, will build on its long history in the community to provide care transition services. The organization will partner with Community Medical Center and St. Patrick Hospital to serve a population living in rural and/or small metropolitan communities across one of the largest rural frontier states in the nation.

Nebraska/Iowa

UniNet Healthcare Network
A clinically integrated Physician Hospital Organization located in Omaha, Nebraska, that will partner with five acute care hospitals in Omaha: Alegent Health Bergan Mercy Medical Center, Alegent Health Immanuel Medical Center (a high readmission hospital), Alegent Health Lakeside Hospital, Alegent Health Midlands Hospital, Alegent Health Mercy Hospital in Iowa, and the Eastern Nebraska Office on Aging to provide care transition services to Medicare beneficiaries.
UniNet Healthcare Network Detailed Summary (PDF)

New Jersey

Central New Jersey Care Transition Program
The Central New Jersey Care Transition Program, led by the Visiting Nurse Association Health Group, will coordinate readmission efforts among six hospitals, three Area Agencies on Aging, community-based providers and organizations across three New Jersey counties. With a particular focus on high readmission histories, the Program’s target population also includes key diagnoses and highly-targeted social risk factors. Hospital partners include CentraState Medical Center, Raritan Bay Medical Center, Robert Wood Johnson University Hospital, Robert Wood Johnson University Hospital at Rahway, Saint Peter's University Hospital, and Trinitas Regional Medical Center.

New York

Brooklyn Care Transition Coalition
Providing transition services and assistance to Medicare fee-for-service beneficiaries across 26 zip codes throughout northern and central areas of Brooklyn. The Cobble Hill Health Center will serve as the lead CBO, partnering with The Brooklyn Hospital Center, the Interfaith Medical Center, and Independent Living Systems, Inc.
Brooklyn Care Transition Coalition Detailed Summary (PDF)

Dominican Sisters Family Health Service, Inc.
Building on a series of care transition pilots, Dominican Sisters Family Health Service, Inc., located in Long Island, New York, will spearhead the Suffolk County Community-based Care Transitions Program in partnership with Southampton Hospital and Stony Brook University Hospital. Using the LACE  index risk prediction model for readmissions,, hospitals will identify over 2,000 high-risk Medicare beneficiaries annually to receive the evidence-based Care Transitions Intervention.

Eddy Visiting Nurse Association
The Eddy Visiting Nurse Association (under the Home Aide Service of Eastern New York, Inc.) will coordinate with four local Offices for the Aging, the Columbia Rural Health Consortium, and Greene County Long Term Care Council to expand care transition services in northeastern New York State. Partnering hospitals include: Albany Memorial Hospital, Samaritan Hospital, Columbia Memorial Hospital, St. Peter’s Hospital, and Seton Health.

Isabella Geriatric Center
Isabella Geriatric Center. As one of the oldest and largest skilled nursing facilities in New York City, Isabella Geriatric Center has focused increasing attention on home and community-based services for local residents to avoid hospitalization and institutionalization. Partnering with two health systems, the Bridge to Home program will coordinate a range of community resources with direct, evidence-based transition services for high-risk Medicare beneficiaries. Bridge to Home hospital partners include The Allen Hospital, Columbia University Medical Center, Weill Cornell Medical Center, St. Luke’s Hospital, and Roosevelt Hospital.

Lifespan of Greater Rochester Inc.
Partnering with four acute care hospitals; Rochester General, Unity, Strong Memorial, and Highland Hospitals; two home health agencies; two additional CBOs; and the Finger Lakes Health Systems Agency to provide care transition services to high-risk Medicare beneficiaries across four counties in Western New York State.
Lifespan of Greater Rochester Inc. Detailed Summary (PDF)

Mt. Sinai Hospital
Mt. Sinai Hospital and Mt. Sinai Hospital in Queens are partnering with the Institute for Family Health, a Federally Qualified Health Center network, to provide and expand care transition services to an estimated 4,800 high risk Medicare beneficiaries per year.

New York Methodist Hospital
New York Methodist Hospital will partner with five skilled nursing facilities, two home health agencies, the Brooklyn Housecall Program,and the Heights and Hills of Brooklyn to provide care transition services to high-risk Medicare beneficiaries residing in the Brooklyn area.

North Country Community-based Care Transitions Program
The North Country Community-based Care Transitions Program (NCCTP) is a consortium of two community-based organizations (CBOs) and seven community hospitals in order to serve Medicare beneficiaries across a three-county rural region of upstate New York. Led by the Fort Drum Regional Health Planning Organization, the NCCTP will expand an existing network of services to beneficiaries who are at high risk of poor healthcare outcomes and frequent hospital stays. Participating in the program are: Canton-Potsdam Hospital, Carthage Area Hospital, Inc., Edward John Noble Hospital of Gouverneur, Claxton-Hepburn Medical Center, Lewis County General Hospital, Massena Memorial Hospital, and Samaritan Medical Center.

P2 Collaborative of Western New York, Inc.
Serving as the regional coordinating body for 10 community hospitals across seven rural counties in western New York: Brooks Memorial Hospital (Chautauqua); Jones Memorial Hospital (Allegany); Olean General Hospital (Cattaraugus); Orleans Community Health (Orleans); TLC Health Network Lake Shore Health Care Center (Chautauqua); United Memorial Medical Center (Genesee); Westfield Memorial Hospital (Chautauqua); WCA Hospital (Chautauqua), and Wyoming Community Hospital (Wyoming County). Each participating hospital will collaborate with a local CBO to build upon and expand existing care transition services for Medicare beneficiaries.
P2 Collaborative of Western New York Detailed Summary (PDF)

Queens Care Transitions Collaborative
Led by the New York City Department for the Aging, the Queens Care Transition Collaborative will further existing care transition programs by expanding Care Transition Intervention (CTI) services to additional hospitals and CBOs within New York’s Queens County community. Aimed at decreasing readmission rates for high-risk Medicare beneficiaries, the program includes the development of a regional Queens Care Transition Collaborative. The Collaborative is a network of five acute care hospitals partnering with five community-based aging service providers. Participating hospitals include: Jamaica Hospital Medical Center, Flushing Hospital Medical Center, New York Hospital Queens, Queens Hospital Center, and Elmhurst Hospital Center.

Tompkins County, New York Office for the Aging
Acting as the lead CBO for the Tomkins County Rural Community-based Care Transition Program (TCRCCTP). Serving the Finger Lakes region of rural Central New York, the TCRCCTP will work with Cayuga Medical Center, the County’s sole hospital and multiple local host agencies to improve the quality of care and reduce avoidable hospitalizations among Medicare beneficiaries.
Tompkins County Detailed Summary (PDF)

Visiting Nurse Service of Schenectady & Saratoga Counties, Inc. (VNS)
Visiting Nurse Service of Schenectady & Saratoga Counties, Inc. (VNS) will partner with six community-based organizations and eight acute care hospitals to deliver care transition services in upstate New York. The VNS will provide care transition services across a largely rural area to serve 5,500 Medicare beneficiaries annually. Participating hospitals include: Adirondack Medical Center, Alice Hyde Medical Center, Champlain Valley Physicians Hospital Medical Center, Ellis Hospital, Nathan Littauer Hospital, St. Mary’s Hospital at Amsterdam, Saratoga Hospital, and Glens Falls Hospital.

North Carolina

AccessCare
AccessCare, located in Morrisville, North Carolina, will lead an expansive community coalition that unites 9 hospitals, a care management organization, and Area Agencies on Aging and Aging & Disability Resource Centers to provide seamless patient care for Medicare beneficiaries across an 11-county region in central North Carolina. The partnership will coordinate patient care using the Care Transitions Intervention (CTI)®.. As a member of the Community Care of North Carolina, the organization brings together three major competitive health systems (UNC, Duke, and WakeMed) in the Raleigh-Durham region to form a new, robust partnership for patients. The hospitals include University of North Carolina Hospital, Duke University Hospital, Duke Health Raleigh Hospital, Durham Regional Hospital, WakeMed Raleigh Campus, WakeMed Cary Hospital, Rex Hospital, Maria Parham Hospital, and Johnston Memorial Hospital.

Access East Community-based Transitional Partnership
North Carolina’s Access East Community-based Transitional Partnership will build on existing partnerships to provide transitional care and support services throughout five rural counties in Eastern North Carolina. Access East, the Upper Coastal Plain Council of Governments (Area Agency on Aging), and four hospital partners serve an economically distressed and exceptionally challenged region for health care outcomes. The Partnership’s hospitals include: Nash Health Care Systems, Halifax Regional Medical Center, Wilson Medical Center, Vidant Edgecombe Hospital.

Northwest Triad Care Transitions Community Program (NTCTCP)
The Northwest Triad Care Transitions Community Program (NTCTCP) will partner with an expansive network of hospitals and other providers to address the care transition needs of urban and rural North Carolina populations. Serving as lead community-based organization (CBO), the Northwest Community Care Network will partner with four additional regional CBOs and seven acute care hospitals including: Forsyth Medical Center, Hugh Chatham Memorial Hospital, Lexington Medical Center, Medical Park Hospital, Northern Hospital of Surry County, Thomasville Medical Center, and Wake Forest Baptist Health.

Ohio

Akron/Canton, Ohio Area Agency on Aging (A/C AAA)
Working in partnership with 10 acute care hospitals located within, or geographically contiguous to, the A/C AAA service area in Ohio: Affinity Hospital, Aultman Hospital, and Mercy Medical Center in Stark County; Akron General Medical Center, Summa Akron City Hospital, Summa Saint Thomas Hospital, Summa Barberton Hospital, and Summa Western Reserve Hospital in Summit County; Robinson Memorial Hospital in Portage County; and Summa Wadsworth Rittman Hospital in Medina County.
A/C AAA Detailed Summary (PDF)

Area Office on Aging of Northwestern Ohio, Inc.
Area Office on Aging of Northwestern Ohio, Inc., located in Toledo, Ohio, in partnership with the Hospital Council of Northwest Ohio and three area hospitals, directs the Northwest Ohio Care Transitions Consortium. Approximately 1,500 high-risk Medicare beneficiaries spanning 10 counties will receive the Care Transitions Intervention annually. Hospital partners include Mercy St. Vincent Medical Center, ProMedica Toledo Hospital, and the University of Toledo Medical Center.

Community Care Connection
Ohio’s Community Care Connection will target at-risk Medicare beneficiaries by a tailored combination of the Care Transition Intervention (CTI), INTERACT II, Disease Zone Management modules, and community based services. Led by the Area on Aging PS2, Inc., hospital partners include: Fort Hamilton Hospital, Greene Memorial Center, Kettering Medical Center, Southview Medical Center, Sion Medical Center, and Sycamore Medical Center.

East Central Ohio Community Care Transitions Coalition
The East Central Ohio Community Care Transitions Coalition, led by Byesville’s Area Agency on Aging Region 9 Inc. (AAA9), is a collaborative effort with local hospitals and numerous down-stream providers within Ohio’s Appalachia Region. Facing this challenge in both rural and medically underserved areas, partner hospitals include Southeastern Ohio Regional Medical Center, Trinity Medical Center East and Trinity Medical Center West, and Union Hospital.

North East Ohio Coalition on Readmissions
The North East Ohio Coalition on Readmissions (NEOCOR) is a local community collaborative led by the Area Agency on Aging 11, Inc. (AAA11). The NEOCOR partnership includes four acute care health system partners (representing seven hospitals), the Community Health initiative (a coalition between UAW General Motors Retirees and the medical directors of the four acute care hospital systems), Youngstown State University, and Allen’s PharmaServ. Hospital partners include: East Liverpool City Hospital, Salem Community Hospital, St. Elizabeth Health Center, St. Elizabeth Boardman Health Center, Northside Medical Center, Trumbull Memorial Hospital, and St. Joseph Health Center.

Ohio AAA Region 8
Partnering with Ohio AAA Region 6, Ohio AAA Region 7, Adena Regional Medical Center, Southern Ohio Medical Center, Marietta Memorial Hospital, Fairfield Medical Center, and Holzer Medical Center to provide care transitions services to beneficiaries residing in a 27-county area spanning rural southern and central Ohio.
Ohio AAA Region 8 Detailed Summary (PDF)

PSA 3 Area on Aging
PSA 3 Area on Aging will lead and expand The Ohio Region 3 Community Care Transitions Project through collaboration with area health partners including; hospitals, nursing facilities, community –based organizations. Confronting both medically-underserved populations and professional shortage areas, the partnership will expand its demonstrable success in implementing care transitions throughout Lima Memorial Hospital, Mercer County Community Hospital, and St. Rita’s Medical Center.

Ohio/Kentucky/Indiana

Southwest Ohio Community Care Transitions Collaborative
Serving the Cincinnati Metropolitan Statistical Area and surrounding counties in Kentucky, Indiana, and Ohio, including the Council on Aging of Southwestern Ohio, the Greater Cincinnati Health Council, HealthBridge, Health Care Access Now, Healthcare Improvement Collaborative, Hamilton County Mental Health and Recovery Services Board, Clinton Memorial Hospital, Jewish Hospital, Mercy Hospital Fairfield, The Christ Hospital, and UC Health University Hospital.
Southwest Ohio Community Care Transitions Collaborative (PDF)

Oregon

Multnomah County Aging and Disability Services
Multnomah County Aging & Disability Services, located in Oregon, will serve as the lead agency overseeing the community coalition that includes three Area Agencies on Aging (AAAs) and four health systems. The AAAs include Clackamas County Social Services, Columbia County Community Action Team, and Washington County Disability Aging and Veterans Services in which they will partner with Legacy Meridian Park Medical Center, Legacy Mount Hood Medical Center, Legacy Good Samaritan Medical Center, Oregon Health & Science University, Adventist Medical Center, Tuality Community Hospital, and Legacy Emanuel Medical Center. The collaborative will serve residents across four counties in the Portland metropolitan area of Oregon. The region includes a combination of urban, suburban and rural communities.

Pennsylvania

Allegheny County Department of Human Services Area Agency on Aging
The Allegheny County Department of Human Services Area Agency on Aging will partner with four hospitals to deliver care transition services in Allegheny County, Pennsylvania. Allegheny will use the Care Transition Intervention Model to serve over 2,900 Medicare beneficiaries annually. The hospitals include: Allegheny General Hospital, Western Pennsylvania Hospital Forbes Regional Campus, Ohio Valley General Hospital, and Jefferson Regional Medical Center.

Delaware County Office of Services for the Aging
Located in Media, Pennsylvania, it will provide care transition services to Delaware County. The program will build off the current experience of the Delaware County Office of Services for the Aging in providing evidence-based care transition services. Five hospitals across Delaware County will participate in the program which includes Crozer Chester Medical Center, Delaware County Memorial Hospital, Riddle Memorial Hospital, Moses Taylor Hospital, and Springfield Hospital.
Delaware County Office of Services for the Aging Detailed Summary (PDF)

North Philadelphia Safety Net Partnership
Partnership between the Philadelphia Corporation for Aging, the Einstein Medical Center and Temple University Hospital, will provide care transitions services to Medicare beneficiaries across 12 zip codes in Northern Philadelphia, many of which have been designated as medically underserved areas.
North Philadelphia Safety Net Partnership Detailed Summary (PDF)

Western Pennsylvania Community Care Transition Program
Building upon the experience of its partners’ participation in the Quality Insights of Pennsylvania’s 9th Scope of Work pilot projects, the Southwestern Pennsylvania AAA, in partnership with the Westmoreland County AAA will serve as the lead CBOs, and are joined by six acute care hospitals across four health systems and a network of sub-acute care providers, including skilled nursing facilities, home health agencies, and personal care homes. Participating hospitals include Monongahela Valley Hospital, The Washington Hospital, Canonsburg General Hospital – part of the West Penn Allegheny Health System, Excela Health Westmoreland Hospital, Excela Health-Latrobe Hospital, and Excela Health-Frick Hospital.
Western Pennsylvania Community Care Transitions Program Detailed Summary (PDF)

York County Area Agency on Aging
The York County Area Agency on Aging, serving as lead for the York/Adams Care Transition Coalition, will partner with local hospitals, the Adams County Office for Aging, and multiple downstream providers across south central Pennsylvania and northern Maryland. The Coalition will assist high-risk Medicare beneficiaries through the Care Transition Intervention along with integrating broad system changes and ongoing quality improvement initiatives. Coalition members include York Hospital, Gettysburg Hospital, and Hanover Hospital.

Rhode Island

Carelink, Inc.
Carelink, Inc., a community-based organization located in Providence, Rhode Island, in partnership with four area hospitals and the broader Providence Transitions Coalition will build on its extensive experience to provide care transition services to high-risk Medicare beneficiaries through the expansion of its Safe Transitions Expansion Program. Approximately 2,000 beneficiaries will be served annually. Hospital partners include Rhode Island Hospital, The Miriam Hospital, Roger Williams Medical Center, and The Fatima Hospital.

South Carolina

Upstate Care Transitions Coalition
The Upstate Care Transitions Coalition, led by the Appalachian Council of Governments Area Agency on Aging, will include more than 25 partners to ensure effective, patient-centered transitions of care and reduce readmission rates in South Carolina’s Cherokee, Spartanburg, and Union Counties. The Coalition includes four acute care hospitals (Mary Black Health System, Spartanburg Regional, Upstate Carolina Medical Center, and Wallace Thomson Hospital) serving beneficiaries in small, rural, and medically underserved areas. The target population includes over 1,000 high-risk Medicare or Medicare / Medicaid dually eligible beneficiaries.

Tennessee

Chattanooga Regional Medicare Community-based Care Transitions Program
The Chattanooga Regional Medicare Community-based Care Transitions Program spearheaded by the Southeast Tennessee Area Agency on Aging and Disability as part of the Chattanooga Regional Health Innovation Coalition will partner with three acute care hospitals across three health systems to deliver care transition services to approximately 1800 high risk Medicare beneficiaries in thirteen rural counties spanning two states. Hospital partners include Erlanger Medical Center, Parkridge Medical Center, and Memorial Healthcare System.

Texas

Area Agency on Aging of Southeast Texas
The Area Agency on Aging of Southeast Texas, a department within the South East Texas Regional Planning Commission, located in Beaumont, will be partnering with multiple hospitals in southeast Texas to serve Medicare beneficiaries residing in Jefferson, Hardin and Orange Counties. The Re-engineered Discharge will be implemented across Christus Hospital, Memorial Hermann Baptist Beaumont Hospital, Memorial Hermann Baptist Orange Hospital, and The Medical Center of Southeast Texas while linking up the highest risk beneficiaries with vital social services package.  

Care Connection Aging and Disability Resource Center (Care Connection)
This CBO has partnered with local hospitals CHRISTUS St. Catherine and Memorial Hermann Katy, skilled nursing facilities, and CBOs immediately west of Houston, Texas. Serving the city of Katy, Texas, the initiative will also include portions of Harris, Fort Bend, Austin, and Walker counties. Established in 1977, Care Connection is a within the Harris County AAA program providing federally-funded social services for individuals aged 60 years and older.
Care Connection Detailed Summary (PDF)

Central Texas Aging and Disability Resource Center
The Central Texas Aging and Disability Resource Center (ARDC) will partner with four area hospitals to provide care transition services throughout 13 Texas counties – all of which contain medically underserved populations and most of which have been identified as Health Professional Shortage Areas. Providing the Care Transitions Intervention (CTI) along with targeted dietary and transportation services, the coalition seeks to assist over 1,400 beneficiaries identified as high-risk for readmission. Partner facilities include: Metroplex Adventist Hospital, Hamilton General Hospital, Hillcrest Baptist Medical Center, and Scott & White Temple Memorial Hospital.

Deep East Texas Council of Governments (DETOG) Area Agency on Aging (AAA)
The Deep East Texas Council of Governments (DETOG) Area Agency on Aging (AAA), as the lead applicant in partnership with five area hospitals, will serve the transition needs of vulnerable populations in the state’s east-central counties of Angelina, Nacogdoches, and Polk. Utilizing both Project Re-Engineered Discharge and the Care Transition Intervention, the partnership will identify at-risk beneficiaries through both specific diagnoses and targeted variables. Participating facilities include, Memorial Health System of East Texas, Woodland Heights medical Center, Memorial Hospital - Nacogdoches, Nacogdoches Medical Center, and Memorial Medical Center - Livingston.

El Paso, Texas Aging and Disability Resource Center
It will partner with surrounding hospitals Providence Memorial Hospital, Sierra Providence Hospital, Sierra Providence East Medical Center, Del Sol Medical Center, and Las Palmas Medical Center, and downstream providers and social service agencies to deliver culturally and linguistically driven community-based care transition services for an ethnically diverse population.
El Paso, Texas Aging and Disability Resource Center Detailed Summary (PDF)

Lower Rio Grande Valley Development Council
The Lower Rio Grande Valley Development Council will assist regional hospitals, the Area Agency on Aging, post-acute care providers, and other community-based organizations throughout the Rio Grande Valley, Texas to implement evidence-based transition interventions for high risk Medicare patients. Hospitals include: Doctors Hospital at Renaissance, Mission Regional Medical Center, South Texas Health System, Edinburg Regional Medical Center, Rio Grande Regional Medical, Valley Baptist-Harlingen, Knapp Medical Center, Valley Regional Medical Center, and Valley Baptist-Brownsville.

Virginia

Appalachian Community Transitions (ACTion) Project
The Appalachian Community Transitions (ACTion) Project spearheaded by the Appalachian Agency for Senior Citizens, an area agency on aging serving the rural, mountainous, and socioeconomically challenged areas of Southwestern Virginia, partners with four acute care hospitals to provide care transitions services to high risk Medicare beneficiaries residing in four counties as they discharge from acute care hospitals. Hospital partners include Clinch Valley Medical Center, Carilion Tazewell Community Hospital, Buchanan County General Hospital, and Russell County Medical Center.

Eastern Virginia Care Transitions Partnership
The Eastern Virginia Care Transitions Partnership, a formal coalition, spearheaded by Bay Aging and consisting of three health systems, seven acute care hospitals, five Area Agencies on Aging, and a multitude of other healthcare providers will deliver an enhanced care transition intervention to over 11,000 high risk Medicare beneficiaries spanning 17 counties in both rural and urban areas. Hospital partners include Stafford Hospital Center, Mary Washington Hospital, Rappahannock General Hospital, Riverside Tappahannock Hospital, Riverside Shore Memorial Hospital, Riverside Walter Reed Hospital, Sentara Williamsburg Regional Medical Center, Mary Immaculate Hospital, and Sentara Careplex Hospital.

Washington

Aging and Long Term Care of Eastern Washington
Aging and Long Term Care of Eastern Washington (ALTCEW), located in Spokane, Washington, will serve an 11-county region in the Eastern part of the state and Northern Idaho. The multi-state initiative spans across large urban and frontier rural communities. The regional partnership includes the Area Agency on Aging of North Idaho (AAANI) and Rural Resources Community Action (RRCA) working with three community hospitals: Providence Sacred Heart Medical Center, Providence Holy Family Hospital, and Kootenai Medical Center. ALTCEW will provide care transition services to Medicare beneficiaries in Spokane and Lincoln counties while RRCA will serve the rural counties of Ferry, Pend Oreille, Stevens and Whitman in Eastern Washington. AAANI will serve beneficiaries living in Benewah, Bonner, Boundary, Kootenai and Shoshone counties in Northern Idaho.

Pierce County, Washington Community Connections’ Aging and Disability Resources
Located in the South Puget Sound region of Washington State, it will partner with the Franciscan Health System, MultiCare Health System, the Pacific Lutheran University School of Nursing, and the Comprehensive Gerontologic Education Partnership to implement a care transitions program while providing a strong model of community collaboration that addresses the unique needs of Medicare beneficiaries in Pierce County.
Pierce County, WA Community Connections’ Detailed Summary (PDF)

Southeast Washington Aging and Long Term Care
An AAA located in Yakima, Washington, it will partner with four hospitals in Yakima, Benton, and Franklin counties that will serve a rural and economically-challenged southeastern part of the state. The hospital partnership includes Kennewick General Hospital, Yakima Valley Memorial Hospital, Yakima Regional Medical and Cardiac Center, and Toppenish Community Hospital. The pogram will build upon the extensive experience of successful community partnerships and collaborations to promote an integrated approach to care transition services for Medicare beneficiaries.
Southeast Washington Aging and Long Term Care Detailed Summary (PDF)

Whatcom Alliance for Healthcare Access
Whatcom Alliance for Healthcare Access, located in Bellingham, Washington, will deliver care transition services to a largely rural areain Whatcom County. The organization will partner with the only hospital in Whatcom County (PeaceHealth St. Joseph Medical Center), including the Northwest Regional Council (Area Agency on Aging) and PeaceHealth Medical Group.



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