Red Bank, NJ - The Centers for Medicare & Medicaid Services (CMS) awarded the  Visiting Nurse Association Health Group and a coalition of hospitals and community groups the CMS Community-based Care Transitions Program (CCTP) in Monmouth, Middlesex and Union counties. The goal of the program is to improve the transition of Medicare beneficiaries with complex medical conditions discharged from hospitals to home or facilities who are at-risk for 30-day hospital readmission.More than 100 sites nationally were selected to participate in the project funded by Sec 3026 of the Affordable Care Act.  Under the Central New Jersey Care Transitions Program (CNJCTP), the coalition group is the first and only current New Jersey program to participate.

The coalition began accepting patients in the demonstration project on August 12, 2013.

The program has the potential to aid 4,000 seniors a year and bring in Medicare funding to support care transition services over two years. VNA Health Group serves as the lead agency and, coalition members includes CentraState Medical Center, Raritan Bay Medical Center, Robert Wood Johnson University Hospital, Saint Peter’s University Hospital, Robert Wood Johnson University Hospital at Rahway, Trinitas Regional Medical Center, RWJ Visiting Nurses, Community VNA, Holy Redeemer Home Care, Monmouth County Division on Aging, Disabilities and Veterans Services, Middlesex County Office of Aging and Disabled Services and Union County Division on Aging, as well as the Jewish Family Service of Central New Jersey.  Healthcare Quality Strategies, Inc. served as the convener for the coalition throughout the application process. 

“The care transitions program will help thousands of at risk seniors safely and successfully return home from the hospital. They will be less likely to “bounce back” to the hospital for preventable reasons, said Dr. Steven Landers, president and CEO of Visiting Nurse Association Health Group. “It is very exciting that this represents a collaboration of many hospitals and community organizations across three counties.”


The coalition members will provide a transitional care program based on evidence informed models of care known to reduce readmissions in clinical trials such as Mary Naylor and Eric Coleman. Nurses or social worker “health coaches” from VNA Health Group and other members, trained in care transitions and chronic illness care concepts will play a critical role in the program’s success.  To learn more about the initiative go to

About VNA Health Group

Visiting Nurse Association Health Group, serving the community for more than 100 years, is the leading nonprofit provider of home health, hospice care and community-based services in New Jersey.  Each year, VNA Health Group serves more than 120,000 individuals throughout the state.  VNA Health Group members include VNA of Central Jersey, Robert Wood Johnson Visiting Nurses, Cape Visiting Nurse Association and VNA of Englewood.  For more information on VNAHG services and programs or to learn how you can make a charitable contribution or become a volunteer visit or call 800-862-3330.