CCTP Site Summaries

There are currently 47 partners of the Community-based Care Transitions Program (CCTP) announced in three rounds. View only: Round 1 | Round 2 | Round 3

The following are site summaries for all CCTP partners:

Arizona

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)

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)

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)

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.

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.

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

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.

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)

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.

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)

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)

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.

Massachussets / 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)

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.

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 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)

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.

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.

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)

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

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)

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)

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)

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)

Texas

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)

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.

Washington

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 program 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 area in 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.