The Community-based Care Transitions Program (CCTP) was established under Section 3026 of the Affordable Care Act to rigorously evaluate innovative models for enhancing patient transitions from hospital settings to various post-acute care environments. This initiative was specifically designed to decrease hospital readmissions among high-risk Medicare beneficiaries, ultimately aiming to improve the quality of care, patient outcomes, and generate measurable cost savings for the Medicare program.
CCTP Partner Organizations
The Community-based Care Transitions Program (CCTP) involved a diverse network of 18 partner sites across the United States, each dedicated to implementing and testing strategies for better care transitions.
Round 1 CCTP Partners
Announced on November 18, 2011:
- Akron/Canton Area Agency on Aging (A/C AAA) (Ohio): Serving communities in the Akron and Canton region of Ohio.
- Maricopa County Area Agency on Aging, Region One (Arizona): Focused on Maricopa County and surrounding areas in Arizona.
- Southwest Ohio Community Care Transitions Collaborative (Ohio): A collaborative effort in the Southwest Ohio region.
Round 2 CCTP Partners
Announced on March 14, 2012:
- Elder Services of Worcester (Massachusetts): Providing services in the Worcester, Massachusetts area.
- Ohio AAA Region 8 (Ohio): Serving communities within Ohio AAA Region 8.
- Senior Alliance, Area Agency on Aging 1-C (Michigan): Focused on the Area Agency on Aging 1-C region in Michigan.
- Western Pennsylvania Community Care Transition Program (Pennsylvania): Serving Western Pennsylvania communities.
Round 3 CCTP Partners
Announced on August 17, 2012:
- Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania): Serving Allegheny County, Pennsylvania.
- Catholic Charities of the Archdiocese of Chicago (Illinois): Providing services within the Archdiocese of Chicago.
- Mt. Sinai Hospital (New York): Based in New York City, New York.
- Somerville-Cambridge Elder Services (Massachusetts): Serving Somerville and Cambridge, Massachusetts.
Round 4 CCTP Partners
Announced on January 15, 2013:
- Aging & In-Home Services of Northeast Indiana (Indiana): Focused on Northeast Indiana communities.
- Partners in Care Foundation (California): Serving communities in California.
- San Diego Care Transitions Partnership (California): A partnership focused on San Diego, California.
- Southern Alabama Regional Council on Aging (SARCOA) (Alabama): Serving Southern Alabama communities.
Round 5 CCTP Partners
Announced on March 07, 2013:
- Kentucky Appalachian Transitions Services (Kentucky): Serving the Appalachian region of Kentucky.
- Sun Health (Arizona): Based in Arizona.
- Top of Alabama Regional Council of Governments (Alabama): Serving the Top of Alabama region.
Understanding the Need for Improved Care Transitions
Care transitions, the periods when patients move between different healthcare settings or providers, are critical junctures in the continuum of care. A significant challenge within the healthcare system is the high rate of hospital readmissions among Medicare patients. Alarmingly, nearly one in five Medicare beneficiaries discharged from a hospital—approximately 2.6 million seniors annually—are readmitted within just 30 days. These readmissions incur substantial costs, exceeding $26 billion every year for the Medicare program.
Traditionally, efforts to reduce readmissions have primarily focused on hospitals, addressing factors within their direct control such as the quality of inpatient care and discharge planning processes. However, a broader perspective recognizes that numerous elements throughout the entire care continuum influence readmission rates. Identifying the key factors contributing to readmissions, both within hospitals and across downstream care providers, is essential for developing and implementing effective interventions to mitigate readmissions.
The Community-based Care Transitions Program (CCTP) was strategically designed to address these shortcomings by fostering collaboration within communities. The program encouraged diverse stakeholders to work together towards shared goals of enhancing healthcare quality, reducing costs associated with avoidable readmissions, and ultimately improving the patient experience during care transitions.
The CCTP is a key component of the Partnership for Patients initiative, a national public-private collaboration with ambitious goals. The Partnership for Patients aims to achieve a 40 percent reduction in preventable hospital errors and a 20 percent reduction in hospital readmissions across the nation.
CCTP Initiative Details and Implementation
Launched in February 2012, the Community-based Care Transitions Program (CCTP) was implemented over a five-year period. Participating organizations were initially granted two-year agreements, with the possibility of annual extensions based on program performance and continued success in meeting program objectives.
Community-based organizations (CBOs) played a central role in the CCTP, utilizing care transition services to effectively manage the transitions of Medicare patients and enhance the overall quality of their care. A total of up to $300 million in funding was allocated to support the CCTP from 2011 through 2015. CBOs received an all-inclusive payment per eligible patient discharge. This payment structure was designed to cover the costs of providing care transition services at the individual patient level, as well as supporting the implementation of systemic improvements at the hospital level to facilitate smoother transitions. Notably, CBOs were compensated only once per eligible discharge within a 180-day period for any given Medicare beneficiary, ensuring efficient resource allocation.
CCTP Eligibility Criteria
The Community-based Care Transitions Program is no longer accepting new participants, and there are currently no plans to expand the program with additional sites.
Eligibility to apply for the CCTP was open to Community-Based Organizations (CBOs), or acute care hospitals that partnered with CBOs. Applicants were required to submit detailed proposals outlining their planned care transition intervention strategies for Medicare beneficiaries within their communities who were identified as being at high risk for hospital readmission. Eligible CBOs were required to demonstrate experience in providing care transition services across the continuum of care and possess established formal working relationships with acute care hospitals and other relevant providers involved in post-acute care.
Furthermore, applicant CBOs were required to be physically located within the community they proposed to serve. They also needed to be legally recognized entities capable of receiving payments for services rendered and have a governing body that included representation from a diverse range of healthcare stakeholders, including patient or consumer representatives. In the selection process, preference was given to Administration on Aging (AoA) grantees who were already actively providing care transition interventions in collaboration with multiple hospitals and practitioners. Priority was also given to entities demonstrating a commitment to serving medically underserved populations, smaller communities, and rural areas, recognizing the unique challenges faced in these settings.
For any inquiries or questions regarding the Community Care Transitions Program, please contact: [email protected]
