The Community-based Care Transitions Program (CCTP), a pivotal initiative born from Section 3026 of the Affordable Care Act, was designed to rigorously test innovative models aimed at refining care transitions for Medicare beneficiaries as they move from hospital to diverse post-acute care settings. A central focus of the program was to significantly decrease hospital readmission rates among high-risk individuals. The overarching objectives of the CCTP were multifaceted: to smooth the transition process for beneficiaries moving from inpatient hospital environments to other necessary care settings, to tangibly improve the overall quality of care received, to achieve a measurable reduction in hospital readmissions specifically for beneficiaries identified as high-risk, and critically, to meticulously document demonstrable cost savings for the Medicare program.
The Collaborative Network of CCTP Partners
The Care Transitions Program was implemented through a network of 18 carefully selected participating sites, each contributing to the collective effort of enhancing care transitions.
Round 1 Partners: Initial partners announced on November 18, 2011, included:
- Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio)
- Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona)
- The Southwest Ohio Community Care Transitions Collaborative (Ohio)
Round 2 Partners: Further expansion announced on March 14, 2012, brought in:
- Elder Services of Worcester, Massachusetts (Massachusetts)
- Ohio AAA Region 8 (Ohio)
- Senior Alliance, Area Agency on Aging 1-C (Michigan)
- Western Pennsylvania Community Care Transition Program (Pennsylvania)
Round 3 Partners: Partnerships expanded again on August 17, 2012, with:
- Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania)
- Catholic Charities of the Archdiocese of Chicago (Illinois)
- Mt. Sinai Hospital (New York)
- Somerville-Cambridge Elder Services (Massachusetts)
Round 4 Partners: Announced on January 15, 2013, the program welcomed:
- Aging & In-Home Services of Northeast Indiana (Indiana)
- Partners in Care Foundation (California)
- San Diego Care Transitions Partnership (California)
- Southern Alabama Regional Council on Aging (SARCOA) (Alabama)
Round 5 Partners: The final round of partners, announced March 07, 2013, included:
- Kentucky Appalachian Transitions Services (Kentucky)
- Sun Health (Arizona)
- Top of Alabama Regional Council of Governments (Alabama)
Understanding the Importance of Care Transitions
Care transitions are defined as the periods when a patient moves between different healthcare providers or healthcare settings. A concerning statistic reveals that approximately one in five Medicare patients discharged from a hospital – equating to about 2.6 million seniors annually – are readmitted within just 30 days. This alarming rate of readmission incurs costs exceeding $26 billion each year. Historically, hospitals have been the primary focus of efforts to curb readmissions, concentrating on elements directly under their control. These include the quality of care administered during hospitalization and the effectiveness of discharge planning procedures. However, it’s increasingly recognized that a multitude of factors across the entire care continuum contribute to readmissions. Therefore, pinpointing the critical factors driving readmissions for a specific hospital and its network of downstream providers is an essential initial step. This identification allows for the strategic implementation of targeted interventions specifically designed to effectively reduce readmission rates.
The CCTP initiative directly addressed these gaps by fostering a collaborative community approach. It encouraged various stakeholders within a community to unite and cooperate, aiming to collectively enhance the quality of healthcare services, reduce overall costs, and significantly improve the patient experience during care transitions.
The CCTP is an integral component of the Partnership for Patients, a nationwide collaborative effort between the public and private sectors. This larger partnership is dedicated to achieving ambitious goals: a 40 percent reduction in preventable errors within hospitals and a 20 percent decrease in hospital readmissions nationwide.
Initiative Details: How the Care Transitions Program Operated
Launched in February 2012, the Care Transitions Program was structured as a 5-year initiative. Participating organizations were initially granted two-year agreements, with the possibility of annual extensions based on demonstrated performance throughout the program’s duration.
Community-based organizations (CBOs) were central to the program’s implementation, utilizing specialized care transition services to effectively manage the transitions of Medicare patients and elevate their overall quality of care. A substantial total funding pool of up to $300 million was allocated for the years 2011 through 2015 to support this program. CBOs received an all-inclusive payment for each eligible discharge. This payment was calculated based on the costs associated with providing care transition services at the individual patient level, as well as the expenses related to implementing systemic improvements at the hospital level. Importantly, CBOs were compensated only once per eligible discharge within a 180-day period for any single beneficiary, ensuring efficient resource allocation.
Eligibility Criteria for Participating in Care Transitions Program
Currently, there are no provisions for adding new sites to the Care Transitions Program.
To be eligible to apply, organizations needed to be Community-Based Organizations (CBOs), or acute care hospitals partnering with CBOs. Applications had to detail the proposed care transition intervention strategies for Medicare beneficiaries within their communities who were identified as being at high risk of hospital readmission. A prerequisite for interested CBOs was the provision of care transition services across the complete continuum of care. Furthermore, they were required to have established formal partnerships with acute care hospitals and other providers operating along the care continuum.
An essential eligibility criterion was that the applying CBO must be physically located within the community it proposed to serve. It also needed to be a legally recognized entity capable of receiving payments for services rendered and have a governing body that included representation from a diverse range of healthcare stakeholders, including consumer advocates. In the selection process, preference was given to Administration on Aging (AoA) grantees who were already delivering care transition interventions in collaboration with multiple hospitals and practitioners. Additional preference was given to entities providing services to medically underserved populations, smaller communities, and rural areas, aiming to address healthcare disparities.
For any inquiries or comments regarding the program, individuals were directed to contact: [email protected]
Program Evaluations and Reports
Latest Evaluation Report
Prior Evaluation Report
Additional Resources
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