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AAMC Members Named as Participants in CMMI Program to Reduce Readmissions of High-Risk Seniors

March 16, 2012—The Center for Medicare and Medicaid Innovation (CMMI) March 14 named 23 new participants in the Community-based Care Transitions Program (CCTP). Each CCTP participant is a community-based collaborative that includes local hospitals, social service providers, and others. The groups work as partners to prevent medical errors and readmissions among “high-risk” Medicare beneficiaries who are discharged to a nursing home, their own home, or another location after hospitalization.

Established under the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152), the CCTP provides participants with a flat fee for coordinating patient care after discharge. The ACA provided CCTP with $500 million over five years.

Several AAMC member institutions are among the participants in the new CCTPs:

  • University of Arkansas for Medical Sciences Academic Medical Center (CareLink Program);

  • Arizona Health Sciences Center (Carondelet Chronic Care Navigation Program);

  • Yale-New Haven Hospital (Greater New Haven Coalition for Safe Transitions);

  • Hospital of Saint Raphael (Greater New Haven Coalition for Safe Transitions);

  • Rush University (AgeOptions);

  • Rush University Medical Center (AgeOptions);

  • Advocate Lutheran General Hospital (AgeOptions);

  • MacNeal Hospital (AgeOptions);

  • Berkshire Medical Center (Elder Services of Berkshire County);

  • UMass Memorial Health Care (Elder Services of Worcester);

  • Henry Ford Health System (Michigan Area Agency on Aging 1-B);

  • William Beaumont Hospital System (Michigan Area Agency on Aging 1-B);

  • St. John Hospital and Medical Center (St. John Providence Health System);

  • Oakwood Hospital and Medical Center (The Senior Alliance, Area Agency on Aging 1-C);

  • Oakwood Healthcare System (The Senior Alliance, Area Agency on Aging 1-C);

  • Strong Memorial Hospital (Lifespan of Greater Rochester, Inc.);

  • Brooklyn Hospital Center (Brooklyn Care Transition Coalition);

  • Crozer-Chester Medical Center (Delaware County Office of Services for the Aging);

  • Einstein Medical Center (North Philadelphia Safety Net Partnership);

  • Temple University Hospital (North Philadelphia Safety Net Partnership);

  • West Penn Allegheny Health System (Western Pennsylvania Community Care Transition Program); and

  • Memorial Hermann Health System (Care Connection).

In Nov. 2011, CMMI announced the first round of CCTPs, which also included several AAMC members among the participants:

  • Emory University Hospital Midtown (Atlanta CCTP);

  • Akron General Medical Center (Akron/Canton Area Agency on Aging);

  • Summa Health System (Akron/Canton Area Agency on Aging);

  • UC Health University Hospital (Akron/Canton Area Agency on Aging);

  • Maine Medical Center (Southern Maine Agency on Aging/Aging and Disability Resource Center);

  • Scottsdale Healthcare-Osborn Medical Center (Area Agency on Aging, Region One); and

  • Northwestern Memorial Hospital (Council for Jewish Elderly).


Christiane Mitchell
Senior Director Health Care Affairs
Telephone: 202-828-0461


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806