CCTP Site Summaries

CCTP Site Summaries


There are currently 18 partners of the Community-based Care Transitions Program (CCTP) announced in three rounds. View only: Round 1 | Round 2 | Round 3 | Round 4 | Round 5

The following are site summaries for all CCTP partners:


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.

Top of Alabama Regional Council of Governments
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.


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)

Sun Health
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.


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.


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.


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.


Kentucky Appalachian Transitions Services
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.


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.


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)

New York

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.


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)


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)


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.

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)

Page Last Modified:
09/06/2023 05:05 PM