Success Story

The Greater Wisconsin Agency on Aging Resources, Inc.


The Greater Wisconsin Agency on Aging Resources, Inc. (GWAAR) is one of three Area Agencies on Aging (AAAs) focused on providing resources to aging populations in Wisconsin. GWAAR supports local Aging and Disability Resources Centers (ADRCs) that provide programs and services for adults over the age of 60 as well as veterans and people with disabilities across 70 counties and 11 tribes.

Along with trying to meet complex client needs represented across such a large area, providing health-care resources also continues to be a challenge. Demand for programs and services among aging populations has increased by 26% annually, and funding hasn’t increased to provide resources since the Older Americans Act passed in 2010. In addition to funding gaps, another major concern for providing necessary health-care services includes finding qualified caregivers.

To optimize limited resources in the communities they serve, GWAAR has been engaged with the Care Transition Intervention® (CTI) on two separate occasions. They first began using the CTI model in 2008, when the Aging and Disability Resource Center of Eau Claire County introduced it, using subsidies from a federal grant. When the funding stream discontinued so did the relationship with the local hospital. In 2018, the program was reinvigorated within GWAAR by new business development resources who understood the program’s previous success in enhancing care coordination in the area. While the re-engagement was slowed by COVID, GWAAR has been incorporating CTI since 2020, and recently adopted CCS Health™ technology solutions to leverage their outcomes and easily show program impact.

  • Prove efficacy of the program to increase full-dollar reimbursement from various payer sources within the health sector
  • Partner with health-care systems and hospitals as referral partners
  • Improve readmission rates and health outcomes for clients who complete the 30-day CTI process
Our Partnership

Since 2020, the Wisconsin Chronic Disease Program (WCDP) and State of Wisconsin have been engaged with GWAAR to build a plan to address the increasing demand for its services and create a community health network. The state and chronic disease program understood that coaching was an integral part of the strategy given the prior success with CTI.

GWAAR currently employs several full-time Community Health Workers who are trained as CTI Transition’s Coaches®. These professionals divide their time between their care-coordination responsibilities and CTI coaching, which makes it more imperative that they have effective systems in place to document client interactions, progress, and outcomes. After understanding their workflow and goals, we helped them implement CTI+, which incorporates our­ CCS Health™ technology solution with the training. This allows them to get better at defining their distinct role responsibilities as a Coach (short-term skill development) versus as a CHW (hands-on support). GWAAR also uses CTI+ to support their growing reporting needs. Recognizing that a stronger partnership between public health service organizations and private health-care systems and hospitals is the natural next step, GWAAR is using the scaled-up reporting to capture and share the positive outcomes they are already seeing with larger organizations. Their goal is to demonstrate the program’s efficacy and prove to private entities the patient and economic value of becoming engaged with the referral process.

While there have been some roadblocks that have delayed a ramp-up in the referral process, GWAAR and their CTI Transition’s Coaches® have already reduced readmission and uncovered medication discrepancies for the clients they’ve served.

In the first nine months after implementing CTI+, which includes the CTI program and CCS Health™ technology, GWAAR achieved the following outcomes:
  • None of the 37 clients that CTI Transition’s Coaches® served in their first months were readmitted, except one for an unrelated medical event and who restarted the 30-day process for the individual client. The national readmission average is 15.5%, with an average readmission cost of $15,200, according to the Agency for Healthcare Research and Quality. Thus, this outcome resulted in an estimated savings of $562,400 between the clients and health-care organizations
  • The part-time CTI Transition’s Coaches® discovered and resolved 4 medication discrepancies in the first several months. On average, patients are more than two and a half times more likely to readmit in their first 30 days as a result of just one medical discrepancy according to research from the Frontiers of Pharmacology
  • Successfully documented 181 client encounters using CCS Health™, making it easier to quickly pull reports for reimbursement and track client progress
  • Strengthened the referral processes from referral organizations, including managed care organization and rural Aging and Disability Resource Centers through Community Health Workers
  • Referring organizations reported improvements in client-satisfaction scores among those who used the services

“In Wisconsin, [CTI’s model] has emerged to create synergy with state systems, health-care systems, and other organizations. If you think about the solar system, the sun is at the center. CTI is the sun and all of these organizations orbit around it. It’s bringing us closer together and linking us together around a single service that benefits clients.”

– Sky Van Rossum, Special Projects Coordinator, Greater Wisconsin Agency on Aging Resources (GWAAR)