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Care Transitions Intervention®


Reduce Risk.
Connect Resources.
Support Social Care.

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Powerful Technology + Proven Coordinated Care Success = Revolutionizing Your Organization

CTI Ven Diagram

This is where your Value-Based Care transition gets manageable and measurable. CTI+ combines precision software with evidenced-based approaches to social care coordination to minimize risk, create sustainable safety nets, streamline referrals, and – ultimately –  improve and maintain community health outcomes. 

With CTI+, your FQHC can support both clinical and social care in a single, flexible solution. Whichever care model you’re using – Care Transitions Intervention (CTI) Coaches, Community Health Workers (CHWs), or another  – we can support you with our full suite of referral, documentation, tracking, and reporting tools. 

Additionally, FQHCs can now extend the same visibility and patient support data into the community by harnessing the power of our Community Health Record (CHR). By activating area social service agencies and service providers, you can transform siloed services into well-coordinated, interconnected resources that offer community members in need “no-wrong-door access” to the social and clinical services provided by your FQHC.

This is a big “plus” for FQHCs and the communities you serve.

We’re Ready to Guide Your FQHC Organization to:

Drive Measurable Outcomes
Over the past 10 years, our solutions have driven improved outcomes across the nation for statewide and community social health initiatives, with results like these:

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Generated $30 million+ in sustainable, value-based payments.
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Supported social services with up to 98% closed-loop referrals
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Reduced low birth-weight babies by over 50% 

We’ll help you enhance your existing referral and assessment process, leveraging your EMR data and augmenting it with innovative analytical and measurement tools.
“[We] didn’t have any systematic way to coordinate services outside of excel spreadsheets…We now have a single system for standardization and consistency, ensuring clients across the state are matched with equitable services to address social and economic needs.”Pama Joyner, Director, COVID-19 Care Coordination Project, Washington State Department of Health

Mobilize Powerful Technology
More than 60 communities nationwide use our ground-breaking technology framework to blend healthcare and social services interactions into a single view of participants’ wellness needs. CTI+ seamlessly allows you to: 

  • Integrate with multiple data sources and systems, including 80+ EHRs
  • Promote ongoing program growth across – and beyond – the care lifecycle, from clinic to kitchen table
  • Orchestrate services and educations for populations with chronic care management needs

With over 10 years of proven results, our technology provides the simplest, shortest path to the highest, ongoing impact for patients, families, and community stakeholders – and we can implement in as little as 30-days!

Get Data Insights
We augment your clinical data with social care coordination tracking and analytics, making it easy to be data-driven in your efforts grow and strengthen
your programs and services, tailoring them to both individual and community needs. 

  • Track and support non-clinical program data in an easy-to-use format
  • Drill down from state impact all the way down to the ZIP level
  • View progress and impact reports in real-time
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pathway activity chart
Newly Referred Chart

Dynamic visual reporting enables administrators and analysts to see community data in a variety of ways. You’ll be able to monitor your data from participant intake, to assessment, to service completion, and even to regulatory reporting – making continuous quality improvement (CQI) easier to maintain.

Transition with Ease
We’ve helped dozens of organizations like yours generate sustainable business models for transitioning to and delivering value-based care. Our powerful combination of tools helps you:

  • Manage staff, partner, and payer contracts
  • Demonstrate ROI of patient  engagement in managing their own health
  • Track, measure, and communicate costs, risks, and outcomes directly tied to reimbursement and APM incentive payments
  • Use data stories to create sustainability beyond limited Federal 330 funding

Paired with CHW and/or Care Transitions Intervention Coaching, our platform provides targeted responsiveness and tailored support for equitable, whole-person care. CTI+ is designed for flexibility that lets our clients meet the needs of their community members AND care coordination workforce.

Let's Get Started!

Give us 30 minutes to show you how accelerate your current SDoH initiatives and make a deeper, more connected impact on the communities you serve – at the kitchen table or wherever community members seek your services.
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Discover How CTI+ Can Revolutionize Your Organization

For More Information, Schedule a Call With Brent


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Brent T. Feorene, MBA
Senior Vice President, Business Development

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Brent leads Business Development at CCS Health, providers of Care Transitions Intervention® and CTI+ services, where he shapes business development strategy & infrastructure and creates strategic partnerships.

Brent gained deep experience consulting with a broad spectrum of healthcare organizations, from community-based to national advisory firms. His work with USAging demonstrates his passionate belief in the power of community-based care to improve health outcomes, lower costs, and change lives. He has presented, facilitated, and led sessions at several USAging conferences and also earned preferred consultant status for a number of years, during which he worked with multiple AAAs to develop integrated programming with health systems and payers to address SDoH.

Brent values a health system that embraces the whole person and empowers individuals on their health journey. He is proud to serve as an ambassador for CCS Health.
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Michelle Comeau
Vice President, Care Transitions Intervention® 

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Michelle leads CTI training, program development, and on-going engagement and support of Transitions Coaches® in the international network of CTI Program Providers. She guides new partners through a readiness process to ensure successful CTI implementation.

In her 10+ years in evidence-based health promotion programs, Michelle has worked with countless organizations to facilitate, train, and support professionals at the local, county, and state levels. Michelle served as an advocate, instructor, community-workshop leader, and a county program manager for multiple Stanford University Chronic Disease Self-Management Programs (CDSMP).

As statewide Director of Development for the Wisconsin Institute for Healthy Aging, Michelle played a key role in directing training programs, developing toolkits, and providing proactive supports to community liaisons.

Michelle is proud of her talent for guiding people to help others in the most effective and fun way possible.
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