Funder: Robert Wood Johnson Foundation

October 2017 | Profile


The Eastern Virginia Care Transitions Partnership (EVCTP) in southeastern Virginia is designed to reduce hospital readmissions and improve quality of care among older adults and those with complex illness through an evidence-based care transition model and in-home assessments. This unique collaborative effort is a large-scale partnership including Bay Aging and four other Area Agencies on Aging (AAAs), four health systems, three managed care organizations (MCOs), and other health care and human service providers.

This profile features a collaborative in Virginia including more than 80 health care and social services organizations, which is designed to reduce hospital readmissions and improve quality of care by using evidence-based care transition coaching and in-home assessments.