Community-Based Care Transitions Program

This program is no longer active.


Building on the success of our three collaboratives to Improve Transitions of Care, in 2011 we focused on preparing organizations for new opportunities to improve care coordination and care transitions. We also focused on providing them with the resources necessary to pursue federal opportunities such as the Community-Based Care Transitions Program.

The Community-Based Care Transitions program was an initiative that derived from the Affordable Care Act, providing $500 million in federal funding for community-based organizations to form partnerships with hospitals to improve care transitions and reduce unnecessary hospital readmissions.

To help organizations in western and central New York take advantage of this opportunity by securing new Medicare funding, we supported the development of two applications for the Community-Based Care Transitions through grant funding and expertise provided by its advisors.

In 2012, the Centers for Medicare and Medicaid Services announced that two sites in western and central New York were among 23 around the nation to be selected as the second group of partners of the Community-based Care Transitions Program.


The Western New York Rural Care Transitions Consortium serves 2,892 Medicare patients per year, bringing more than $700,000 in Medicare reimbursement into the community and resulting in more than $1.25 million annual savings to Medicare by reducing re-hospitalizations. It’s anticipated that the Tompkins County project will serve more than 400 Medicare patients per year, bringing approximately $106,000 in Medicare reimbursement to the community and saving Medicare a projected $115,000 annually by reducing re-hospitalizations.

Program Partners

Collaborative Partners

Funded Partners

Cayuga Medical Center