CCS Health™ Training | Community Health Worker.

Our Community Health Worker (CHW) Fundamental training is delivered in-person or online in three-to-seven week sessions. During the program, new and experienced Community Health Workers become CCS CHW Care Coordinators by building skills in relationship building, coaching, home visiting, trauma-informed care, basic organization, and care coordination through group activities. Through the cohort, CHWs also develop a collaborative network with work peers, making them more resilient and effective in their roles in their communities.

Along with role-based learning, participants develop competency in our Community Health Record and other CCS Health systems. We find that by incorporating technology and aligning to our data-collection standards, trained CHWs can convert more of their work to payments and high-quality data for their organizations.

  • Basic competencies align with the National Community Health Worker Study, Community Health Worker Core Consensus Project (C3)
  • Practicum (~120 hours) is completed with the trainee’s agency to enhance practical application of care-coordination skills
  • Graduates receive a CCS CHW Care Coordinator certificate
  • Must be paired with our CCS Health solutions

Number of Community Health Workers who have received their CCS CHW Care Coordinator certificate.


Rate of closed-loop referrals completed with CCS Health®; this is compared to a 4% industry average.


Many CCS Health CHW graduates have become agency supervisors, HUB managers and community health specialists at state Department of Health Services or other Public Health programs.

Care Transitions Intervention® Training | Transitions Coach®.

Care Transitions Intervention (CTI) is a 30-day evidence-based model designed to support patients transitioning from hospital to home. During the program, patients with complex needs (and/or family caregivers) work with a Transitions Coach to navigate this crucial, overwhelming time while building health self-management skills that have lasting long-term impacts on quality of life and well-being. The intervention consists of five encounters: a hospital visit (when possible), a home visit, and three follow-up phone calls after the home visit.

When our evidence-based coaching model is coupled with technology, we streamline tracking and reporting, and with bi-directional information flow, extend the use of existing information to reduce data entry and reduce manual errors.

  • Evidence-based training delivered to client-management employees or contractors
  • Access to the monthly CTI Community Learning call; a peer-driven advanced educational resource/offering
  • Track Care Transitions Intervention metrics (e.g., medication discrepancies, patient activation, skill development, etc.) with CTI+
  • Able to run alongside our CCS Health™ solutions

Highest percentage of reduced readmission experienced by hospitals that implement CTI. Average reduced readmission between 20% and 70%.


Rate of closed-loop referrals completed with CCS Health®; this is compared to a 4% industry average.


Annual net savings (per coach) for risk-taking organizations that employ Transitions Coaches.

Activating patients to take charge of their health is easier said than done. Attend a free webinar or schedule a consultation to learn how providers can shift patient health trajectories within transitions of care (and beyond).