CCTP Partners: Round 5 Site Summaries

The CCTP is a five-year program created by the Affordable Care Act. Participants sign two-year program agreements with CMS, with the option to renew each year for the remainder of the program, based on their success.

The following is information for the Round 5 (Mar. 07, 2013) CCTP partners.


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.



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.



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.

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.

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.



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.



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.



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.



Green River Area Development District
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.



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.



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.


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

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.



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.

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.



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.



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.  

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.