CCTP Partners: Round 4 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 4 (Jan. 15, 2013) CCTP partners.

Alabama

Southern Alabama Regional Council on Aging (SARCOA)

Agreement Date: 03/31/2016
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.

California

Partners in Care Foundation

Agreement Date: 04/30/2016
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

Agreement Date: 12/31/2015
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.

Indiana

Aging & In-Home Services of Northeast Indiana

Agreement Date: 08/31/2015
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.