Eastern Virginia Care Transitions Partnership


  • Proven strategy to increase chronic care coordination in rural, medically underserved areas throughout Virginia
  • Use of care coordination teams to offer Medicare patients the tools they need to meaningfully engage with healthcare providers
  • Effectively utilize primary care providers to meet the goals of maximizing healthcare outcomes for Medicare patients living with chronic illnesses
  • Blends an extensive portfolio of services for long-term care and
    community supports with pre– and post-acute care, and prevention activities that include the social model of evidence-based intervention
  • Delivers supportive services that include transportation, home delivered meals, emergency medication purchase assistance and connections to other home and community programs
  • Demonstrates continued positive trend toward further readmission rate reductions resulting in lower healthcare costs
  • Virginia leader in demonstrating that by providing chronic disease self-management education, advance care planning, streamlining care coordination,utilizing prevention practices and other evidence-based programs, Virginians will receive quality healthcare outcomes with lower healthcare costs
2015—Virginia Center for Health Innovations appoints EVCTP to expand Care Transitions statewide
2015—Recognized by CMS as a National Top Performer for Care Transitions Intervention
2015—Winner n4a Aging Innovations & Achievement Award for Care Transitions
2014—Winner Commonwealth Council on Aging Best Practices Award for EVCTP
2014—Winner Virginia Health Care Innovators and Virginia Chamber of Commerce Award for Care Transitions
2013—Awarded CMS Reimbursement Project for Care Transitions Intervention