Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Appendix F. Examples of Community-based CARE Transition Program with LTPAC/LTSS Participation

10/29/2013

TABLE F-1. Examples of Community-Based Care Transition Programs with LTPAC or LTSS Participation

  ACO     Service Area     LTPAC/LTSS Provider Type  
Aging & Long-Term Care of Eastern Washington Eastern Washington In-Home Services
Southeast Washington Aging & Long-Term Care Southeast Washington In-Home Care, ADC, HCRR
Eddy Visiting Nurse Association Upstate New York HHA
Advanced Care Transitions (ACT) Marin County, California Long-Term Care Ombudsman, In-Home Support Service
Community SeniorServ Southern California Meals on Wheels, Senior Lunch Program, Adult Day Services
Jewish Home for the Aging Geriatric Services Inc. San Fernando Valley, California Rehabilitative Services, Independent Living Facilities, ALF, SNFs, Dining & Nutrition at Home, Hospice Care, Senior Centers
Los Angeles Mid-City Integrated Care Collaborative Los Angeles, California SNFs, Rehabilitation Centers, CBOs
Catholic Health Care Transitions Services, Inc. Southeast, Florida HHA, SNF
Osceola-St. Cloud Community-Based Care Transitions Coalition Osceola-St. Cloud, Florida SNF
Elder Options Mid-Florida HHA, SNF
AgeOptions (with Rush University Medical Center [RUMC] Care Transitions Program) Cook County, Illinois LTSS, HHA, SNF
Southern Alabama Regional Council on Aging (SARCOA) Southern Alabama In-Home Service, Independent Living, ALF, SNFs
Top of Alabama Regional Council of Governments (TARCOG) Northern Alabama HCBS
Community Connections' Aging & Disability Resources Pierce County, Washington Long-Term Care Ombudsman, Adult Day Services, In-Home Support Services, Nutrition Services & Senior Centers
Eastern Virginia Care Transitions Partnership Eastern Virginia ADC, Home Care/Personal Care, Meals on Wheels
Appalachian Community Transitions (ACTion) Project Southwestern Virginia Adult Day Health Care, SNF, Meal Services, Home Care Services
Lower Rio Grande Valley Development Council Lower Rio Grande Valley, Texas Long-Term Care Ombudsman Program, Community Assistance
El Paso, Texas Aging & Disability Resource Center (ADRC) Far West Region, Texas Senior Care Services, Hospice Care
Deep East Texas Council of Governments (DETOG) on Aging (AAA) Eastern Texas ADC, Home-Delivered Meals
Central Texas Aging & Disability Resource Center (ADRC) Central Texas Home Services, ADC, Home-Delivered Meals
Care Connection Aging & Disability Resource Center (ADRC) (Care Connection) West of Houston, Texas Age Well Live Well--Fitness Programs, Fall Prevention, Medication Management, Healthy Living Series, Hospice Care, HHA, Meals on Wheels, Senior Services
Area Agency on Aging (AAA) of Southeast Texas Southeast Texas Home-Delivered Meals, Transportation Services, Long-Term Care Ombudsman Program, Benefits Counseling Program
Chattanooga Regional Medicare Community-Based Care Transitions Program (CCTP) Southeast Tennessee CHOICE Program (in-home services), Congregate Meal Programs, Home-Delivered Meal Services, Homemaker Services, Nutrition Transportation, Senior Centers
Carelink, Inc. Providence, Rhode Island Home Services, SNF
Upstate Care Transitions Coalition Appalachia Area, South Carolina Counseling & Support Groups, Mobility Assistance Programs, ALF, HHA, NHs, Rehabilitation Centers
York County Area Agency on Aging (AAA) Central Pennsylvania & Northern Maryland ADC, Nutrition Services, Personal Care Services, Senior Centers, Transportation Services
Carondelet Chronic Care Navigation Program Southern Arizona Hospice & Palliative Care
Area Agency on Aging (AAA), Region One Maricopa County, Arizona Home-Delivered Meals, Independent Living Facilities, 24hr Senior Help Line
Sun Health Northwest Area of Maricopa County, Arizona SNFs, Independent Living Facilities, ALF, Rehabilitation Centers
CareLink Central Arkansas Meals on Wheels, Home Care, Medication Prescription Drug Counseling, Senior Center
San Diego Care Transitions Partnership San Diego, California Transportation Services, Personal Assistance, Laundry Services, Protective Support

SOURCE: Descriptions of CCTP projects from CMS Innovations web site: http://innovation.cms.gov/initiatives/CCTP/CCTP-Site-Summaries.html.

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