CCTP Partners: Round 3 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. As of the date of this announcement, CMS continues to accept applications and approve participants on a rolling basis as long as funds remain available.

The following is information for the Round 3 (Aug 17, 2012) CCTP partner sites.



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.

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 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.



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.

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 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.



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.



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.



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.



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.

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 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.

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.



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.



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.



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



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.