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
Agreement Date: 07/31/2015
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.
Agreement Date: 04/30/2016
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.
Kentucky Appalachian Transitions Services
Agreement Date: 02/29/2016
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.