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 4 (Jan. 15, 2013) CCTP partners.
Alabama
Southern Alabama Regional Council on Aging (SARCOA)
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
AltaMed Health Services Corporation
AltaMed Health Services Corporation, located in Los Angeles, California, will serve a predominantly low-income medically-underserved population living in the Metropolitan and East Los Angeles urban catchment areas. In collaboration with Hollywood Presbyterian Medical Center, White Memorial Medical Center, Citrus Valley Medical Center and Foothill Presbyterian Hospital and leveraging a regional public-private collaborative consisting of county hospital and the nation’s largest Federally Qualified Health Center (FQHC) with an Independent Practice Association (IPA) in Los Angeles County, AltaMed builds on its long history of serving ethnically diverse and low-income Medicare beneficiaries in Los Angeles County.
Glendale Memorial Hospital and Health Center
Glendale Memorial Hospital and Health Center, as the lead applicant in partnership with Partners in Care Foundation, and two additional hospitals, Glendale Adventist Medical Center and Verdugo Hills Hospital, will serve high-risk Medicare beneficiaries residing in the Los Angeles Counties of Glendale, Burbank, and La Canada-Flintridge. The collaborative will aim to redesign the patient experience and discharge planning process for patients at-risk of readmission in a culturally diverse community of Los Angeles.
Partners in Care Foundation
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
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.
Ventura County Area Agency on Aging
Ventura County Area Agency on Aging will lead a partnership with the Camarillo Health Care District and five hospitals that include Community Memorial Hospital San Buenaventura, St. John’s Regional Medical Center, St. John’s Pleasant Valley Hospital, Simi Valley Hospital & Health Care Services, and Ventura County Medical Center. Based on Ventura’s success piloting care transition intervention across a number of its hospital partners, the program will serve diverse Medicare beneficiaries by providing culturally sensitive transitional care services.
Colorado
Denver Regional Council of Governments
As the designated Area Agency on Aging in the Denver metropolitan area, the Denver Regional Council of Governments (DRCOG) will serve Medicare beneficiaries living in eight counties. A number of patients reside in Medically Underserved Area/Population. The expansive community partnership works across the care continuum leveraging two health systems and multiple downstream providers such as skilled nursing facilities, home health agencies, and various non-profit entities. The hospitals include Exempla Saint Joseph Hospital, Medical Center of Aurora, Sky Ridge Medical Center, Swedish Medical Center, Presbyterian/St Luke's Medical Center, North Suburban Medical Center and Rose Medical Center.
Florida
Catholic Health Care Transitions Services, Inc.
Catholic Health Care Transitions Services, Inc., located in Lauderdale Lakes, will lead a broad-based community collaborative serving Medicare beneficiaries in portions of Miami-Dade and Broward counties in Southeast Florida. In partnership with North Shore Medical Center, Hialeah Hospital, Palmetto General Hospital, and Holy Cross Hospital along with home health agencies, skilled nursing facilities and human services organization across the care continuum, the coalition targets a culturally diverse, low-income and medically underserved population of the state.
West Central Florida Area Agency on Aging
The West Central Florida Area Agency on Aging, Inc. in partnership with eight acute care hospitals, three skilled nursing facilities, and three home health providers will deliver the Care Transitions Intervention® in conjunction with elements of Project RED and BOOST to over 2000 high risk Medicare beneficiaries residing in sixty-four zip codes spanning both rural and urban areas. Hospital partners include: University Hospital at Tampa, University Hospital at Carrollwood, Memorial Hospital of Tampa, Saint Joseph’s Hospital, South Bay Hospital, South Florida Baptist Hospital, Tampa General Hospital, and Town & Country Hospital.
Georgia
Central Savannah River Area Regional Commission
The Central Savannah River Area Regional Commission, an area agency on aging, will partner with three acute care hospitals to provide the Care Transitions Intervention® along with a tailored post-discharge support package to approximately 1,000 high-risk Medicare beneficiaries across fourteen counties in east central Georgia. Partner hospitals include Jefferson Hospital, University Hospital Augusta, and, University Hospital McDuffie.
Northeast Georgia Regional Commission
The Northeast Georgia Regional Commission’s Area Agency on Aging in partnership with four acute care hospitals will deliver the Care Transitions Intervention® along with a supportive service package to high risk Medicare beneficiaries. This community spans twelve counties and represents both rural and medically underserved populations. Hospital partners include Athens Regional Medical Center, Barrow Regional Medical Center, Newton Medical Center, and Walton Regional Medical Center.
Hawaii
Maui County Office on Aging
The Maui Community Partnership (MCP), led by the Maui County Office on Aging (MCOA), will expand ongoing transitions efforts to reduce Medicare hospital readmissions using the Care Transitions Intervention (CTI) Model. The program will serve eligible beneficiaries from Maui’s primary hospital, Maui Memorial Medical Center (MMMC). Maui County has unique geographic and cultural challenges, including that of providing support to individuals on three different islands.
Illinois
Community Research Resource Information Services for Seniors, Inc. (CHRIS)
The Community Research Resource Information Services for Seniors, Inc. (CHRIS) is partnering with three local hospitals to provide care transition services across Illinois’ Champaign and Vermillion Counties. CHRIS will use the Bridge Model with coalition partners who include the East Central Illinois Area Agency on Aging, University of Illinois Center on Health Aging and Disability, social service providers, and a range of related stakeholders. CHRIS partner hospitals include: Carle Foundation Hospital, Provena Covenant Medical Center - Urbana, and Provena United Samaritans Medical Center – Logan.
Indiana
Aging & In-Home Services of Northeast Indiana
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.
Iowa
Siouxland Care Transitions
Siouxland Care Transitions, spearheaded by Siouxland Aging Services, an Area Agency on Aging, located in Sioux City, Iowa will partner with two acute care hospitals, the Siouxland Community Health Center, and the Winnebago Tribe of Nebraska to provide care transition services to over 1500 high risk Medicare beneficiaries including Native Americans. This community spans two states and encompasses rural and medically underserved areas.
Maryland
The Coordinating Center
The Coordinating Center, located in Millersville, Maryland, in collaboration with Bon Secours Hospital, Maryland General Hospital, and University of Maryland Medical Center and Baltimore City Aging & Disability Resource Center will implement a comprehensive care transition program using the Care Transitions Intervention (CTI)®. The community coalition will coordinate care across the continuum for patients primarily living in West Baltimore, a medically underserved region of the city. The organization has extensive experience in providing care transition services to ethnically and socially diverse communities throughout the state.
Michigan
Tri-County Aging Consortium
The Tri-County Aging Consortium (or Tri-County Office on Aging) has partnered with two regional hospitals, Edward W Sparrow Hospital and Ingham Regional Medical Center, and the Chronic Disease Management Collaborative to serve Medicare beneficiaries residing in Clinton, Eaton, and Ingham counties in mid-Michigan (including cities of Lansing and East Lansing). The primary interventions use Project BOOST and the Bridge Model of Transitional Care. The tri-county partnership leverages its prior cooperative structure dating back to 2008.
Mississippi
Three Rivers Planning & Development District
Through the Three Rivers Community-based Care Transitions Program, The Three Rivers Planning & Development District Area Agency on Aging in partnership with the Golden Triangle Area Agency on Aging, six acute care hospitals, multiple home health organizations, skilled nursing facilities, and critical access hospitals will deliver the Care Transitions Intervention® to high risk Medicare beneficiaries residing across ten rural and medically underserved areas of northeast Mississippi. Hospital partners include Baptist Memorial Hospital North Mississippi, Clay County Medical, Gilmore Memorial Hospital, North Mississippi Medical, Trace Regional Hospital, and Webster General Hospital.
Missouri and Kansas
Kansas City Quality Improvement Consortium, Inc.
Serving the Greater Kansas City Bi-State area, the Kansas City Quality Improvement Consortium (KCQIC) is a non-profit community coalition providing a forum for collaboration and encouraging best practices in health care. The KCQIC care transitions partnership includes 15 hospitals, Area Agencies on Aging, physicians and a wide range of downstream providers to reduce readmission rates for high-risk Medicare beneficiaries. Partnering in this effort are: Liberty Hospital, North Kansas City Hospital, Lee’s Summit Medical Center, Centerpoint Medical Center, Research Medical Center, Research Belton Hospital, Saint Joseph Medical Center, Saint Mary’s Medical Center, Truman Medical Center – Hospital Hill, Truman Medical Center -Lakewood, Menorah Medical Center, Olathe Medical Center, Overland Park Regional Medical Center, Shawnee Mission Medical Center, and Providence Medical Center.
Montana
Missoula Aging Services
Missoula Aging Services, an Area Agency on Aging for Missoula and Ravalli counties of Montana, and the Aging and Disability Resource Center for Missoula county, will build on its long history in the community to provide care transition services. The organization will partner with Community Medical Center and St. Patrick Hospital to serve a population living in rural and/or small metropolitan communities across one of the largest rural frontier states in the nation.
New York
Isabella Geriatric Center
Isabella Geriatric Center. As one of the oldest and largest skilled nursing facilities in New York City, Isabella Geriatric Center has focused increasing attention on home and community-based services for local residents to avoid hospitalization and institutionalization. Partnering with two health systems, the Bridge to Home program will coordinate a range of community resources with direct, evidence-based transition services for high-risk Medicare beneficiaries. Bridge to Home hospital partners include The Allen Hospital, Columbia University Medical Center, Weill Cornell Medical Center, St. Luke’s Hospital, and Roosevelt Hospital.
North Country Community-based Care Transitions Program
The North Country Community-based Care Transitions Program (NCCTP) is a consortium of two community-based organizations (CBOs) and seven community hospitals in order to serve Medicare beneficiaries across a three-county rural region of upstate New York. Led by the Fort Drum Regional Health Planning Organization, the NCCTP will expand an existing network of services to beneficiaries who are at high risk of poor healthcare outcomes and frequent hospital stays. Participating in the program are: Canton-Potsdam Hospital, Carthage Area Hospital, Inc., Edward John Noble Hospital of Gouverneur, Claxton-Hepburn Medical Center, Lewis County General Hospital, Massena Memorial Hospital, and Samaritan Medical Center.
Queens Care Transitions Collaborative
Led by the New York City Department for the Aging, the Queens Care Transition Collaborative will further existing care transition programs by expanding Care Transition Intervention (CTI) services to additional hospitals and CBOs within New York’s Queens County community. Aimed at decreasing readmission rates for high-risk Medicare beneficiaries, the program includes the development of a regional Queens Care Transition Collaborative. The Collaborative is a network of five acute care hospitals partnering with five community-based aging service providers. Participating hospitals include: Jamaica Hospital Medical Center, Flushing Hospital Medical Center, New York Hospital Queens, Queens Hospital Center, and Elmhurst Hospital Center.
North Carolina
AccessCare
AccessCare, located in Morrisville, North Carolina, will lead an expansive community coalition that unites 9 hospitals, a care management organization, and Area Agencies on Aging and Aging & Disability Resource Centers to provide seamless patient care for Medicare beneficiaries across an 11-county region in central North Carolina. The partnership will coordinate patient care using the Care Transitions Intervention (CTI)®.. As a member of the Community Care of North Carolina, the organization brings together three major competitive health systems (UNC, Duke, and WakeMed) in the Raleigh-Durham region to form a new, robust partnership for patients. The hospitals include University of North Carolina Hospital, Duke University Hospital, Duke Health Raleigh Hospital, Durham Regional Hospital, WakeMed Raleigh Campus, WakeMed Cary Hospital, Rex Hospital, Maria Parham Hospital, and Johnston Memorial Hospital.
Access East Community-based Transitional Partnership
North Carolina’s Access East Community-based Transitional Partnership will build on existing partnerships to provide transitional care and support services throughout five rural counties in Eastern North Carolina. Access East, the Upper Coastal Plain Council of Governments (Area Agency on Aging), and four hospital partners serve an economically distressed and exceptionally challenged region for health care outcomes. The Partnership’s hospitals include: Nash Health Care Systems, Halifax Regional Medical Center, Wilson Medical Center, Vidant Edgecombe Hospital.
Ohio
Community Care Connection
Ohio’s Community Care Connection will target at-risk Medicare beneficiaries by a tailored combination of the Care Transition Intervention (CTI), INTERACT II, Disease Zone Management modules, and community based services. Led by the Area on Aging PS2, Inc., hospital partners include: Fort Hamilton Hospital, Greene Memorial Center, Kettering Medical Center, Southview Medical Center, Sion Medical Center, and Sycamore Medical Center.
East Central Ohio Community Care Transitions Coalition
The East Central Ohio Community Care Transitions Coalition, led by Byesville’s Area Agency on Aging Region 9 Inc. (AAA9), is a collaborative effort with local hospitals and numerous down-stream providers within Ohio’s Appalachia Region. Facing this challenge in both rural and medically underserved areas, partner hospitals include Southeastern Ohio Regional Medical Center, Trinity Medical Center East and Trinity Medical Center West, and Union Hospital.
North East Ohio Coalition on Readmissions
The North East Ohio Coalition on Readmissions (NEOCOR) is a local community collaborative led by the Area Agency on Aging 11, Inc. (AAA11). The NEOCOR partnership includes four acute care health system partners (representing seven hospitals), the Community Health initiative (a coalition between UAW General Motors Retirees and the medical directors of the four acute care hospital systems), Youngstown State University, and Allen’s PharmaServ. Hospital partners include: East Liverpool City Hospital, Salem Community Hospital, St. Elizabeth Health Center, St. Elizabeth Boardman Health Center, Northside Medical Center, Trumbull Memorial Hospital, and St. Joseph Health Center.
Oregon
Multnomah County Aging and Disability Services
Multnomah County Aging & Disability Services, located in Oregon, will serve as the lead agency overseeing the community coalition that includes three Area Agencies on Aging (AAAs) and four health systems. The AAAs include Clackamas County Social Services, Columbia County Community Action Team, and Washington County Disability Aging and Veterans Services in which they will partner with Legacy Meridian Park Medical Center, Legacy Mount Hood Medical Center, Legacy Good Samaritan Medical Center, Oregon Health & Science University, Adventist Medical Center, Tuality Community Hospital, and Legacy Emanuel Medical Center. The collaborative will serve residents across four counties in the Portland metropolitan area of Oregon. The region includes a combination of urban, suburban and rural communities.
South Carolina
Upstate Care Transitions Coalition
The Upstate Care Transitions Coalition, led by the Appalachian Council of Governments Area Agency on Aging, will include more than 25 partners to ensure effective, patient-centered transitions of care and reduce readmission rates in South Carolina’s Cherokee, Spartanburg, and Union Counties. The Coalition includes four acute care hospitals (Mary Black Health System, Spartanburg Regional, Upstate Carolina Medical Center, and Wallace Thomson Hospital) serving beneficiaries in small, rural, and medically underserved areas. The target population includes over 1,000 high-risk Medicare or Medicare / Medicaid dually eligible beneficiaries.
Tennessee
Chattanooga Regional Medicare Community-based Care Transitions Program
The Chattanooga Regional Medicare Community-based Care Transitions Program spearheaded by the Southeast Tennessee Area Agency on Aging and Disability as part of the Chattanooga Regional Health Innovation Coalition will partner with three acute care hospitals across three health systems to deliver care transition services to approximately 1800 high risk Medicare beneficiaries in thirteen rural counties spanning two states. Hospital partners include Erlanger Medical Center, Parkridge Medical Center, and Memorial Healthcare System.
Texas
Central Texas Aging and Disability Resource Center
The Central Texas Aging and Disability Resource Center (ARDC) will partner with four area hospitals to provide care transition services throughout 13 Texas counties – all of which contain medically underserved populations and most of which have been identified as Health Professional Shortage Areas. Providing the Care Transitions Intervention (CTI) along with targeted dietary and transportation services, the coalition seeks to assist over 1,400 beneficiaries identified as high-risk for readmission. Partner facilities include: Metroplex Adventist Hospital, Hamilton General Hospital, Hillcrest Baptist Medical Center, and Scott & White Temple Memorial Hospital.
Virginia
Appalachian Community Transitions (ACTion) Project
The Appalachian Community Transitions (ACTion) Project spearheaded by the Appalachian Agency for Senior Citizens, an area agency on aging serving the rural, mountainous, and socioeconomically challenged areas of Southwestern Virginia, partners with four acute care hospitals to provide care transitions services to high risk Medicare beneficiaries residing in four counties as they discharge from acute care hospitals. Hospital partners include Clinch Valley Medical Center, Carilion Tazewell Community Hospital, Buchanan County General Hospital, and Russell County Medical Center.
Eastern Virginia Care Transitions Partnership
The Eastern Virginia Care Transitions Partnership, a formal coalition, spearheaded by Bay Aging and consisting of three health systems, seven acute care hospitals, five Area Agencies on Aging, and a multitude of other healthcare providers will deliver an enhanced care transition intervention to over 11,000 high risk Medicare beneficiaries spanning 19 counties in both rural and urban areas. Hospital partners include Stafford Hospital Center, Mary Washington Hospital, Rappahannock General Hospital, Riverside Tappahannock Hospital, Riverside Shore Memorial Hospital, Riverside Walter Reed Hospital, Sentara Williamsburg Regional Medical Center, Mary Immaculate Hospital, and Sentara Careplex Hospital.
Washington
Aging and Long Term Care of Eastern Washington
Aging and Long Term Care of Eastern Washington (ALTCEW), located in Spokane, Washington, will serve an 11-county region in the Eastern part of the state and Northern Idaho. The multi-state initiative spans across large urban and frontier rural communities. The regional partnership includes the Area Agency on Aging of North Idaho (AAANI) and Rural Resources Community Action (RRCA) working with three community hospitals: Providence Sacred Heart Medical Center, Providence Holy Family Hospital, and Kootenai Medical Center. ALTCEW will provide care transition services to Medicare beneficiaries in Spokane and Lincoln counties while RRCA will serve the rural counties of Ferry, Pend Oreille, Stevens and Whitman in Eastern Washington. AAANI will serve beneficiaries living in Benewah, Bonner, Boundary, Kootenai and Shoshone counties in Northern Idaho.
