The Community-based Care Transitions Program (CCTP) was established under Section 3026 of the Affordable Care Act. This initiative was designed to test innovative models for enhancing patient care as they transition from hospital settings to other care environments. A key focus of the CCTP was to significantly reduce hospital readmissions among high-risk Medicare beneficiaries. The overarching goals of the Community Based Care Transitions Program Cctp were multifaceted: improving the transition process for beneficiaries moving from inpatient hospital care to various post-hospital settings, enhancing the overall quality of care received, decreasing the rate of readmissions for patients at high risk, and demonstrating measurable cost savings for the Medicare program.
Image: The official logo for the Community Based Care Transitions Program (CCTP), highlighting its focus on improving patient transitions and healthcare quality.
CCTP: A Network of Partners Dedicated to Care Transitions
The Community Based Care Transitions Program (CCTP) brought together a diverse network of 18 participating sites. These sites played a crucial role in implementing and testing the care transition models developed under the program.
Rounds of CCTP Partners
The selection of CCTP partners was conducted in multiple rounds, reflecting the program’s phased approach to implementation and expansion.
Round 1 Partners
Announced on November 18, 2011, the first round of partners 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
The second round of partner organizations, announced on March 14, 2012, consisted of:
- 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
Partners for the third round were announced on August 17, 2012, and included:
- 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 fourth round of CCTP partners were:
- 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 on March 7, 2013, included:
- Kentucky Appalachian Transitions Services (Kentucky)
- Sun Health (Arizona)
- Top of Alabama Regional Council of Governments (Alabama)
The Critical Need for Community Based Care Transitions Program (CCTP)
Care transitions are a significant point of vulnerability for patients, occurring whenever an individual moves between different healthcare providers or settings. A concerning statistic highlights the magnitude of this issue: nearly one in five Medicare patients discharged from a hospital – approximately 2.6 million seniors – are readmitted within just 30 days. This high rate of readmission carries a staggering annual cost exceeding $26 billion.
Traditionally, hospitals have been at the forefront of efforts to reduce readmissions. Their focus has primarily been on aspects within their direct control, such as the quality of care delivered during hospitalization and the discharge planning process. However, the reality is that numerous factors across the entire care continuum influence readmission rates. To effectively address this challenge, it’s crucial to pinpoint the key factors driving readmissions, not only within hospitals but also in downstream care settings. Understanding these drivers is the essential first step towards implementing targeted interventions that can successfully reduce readmissions.
The Community based care transitions program cctp directly addressed these shortcomings. It fostered a collaborative, community-wide approach to healthcare improvement. By encouraging different community stakeholders to work together, the CCTP aimed to enhance the quality of care, reduce healthcare costs, and improve the overall patient experience during care transitions.
This program is an integral part of the Partnership for Patients, a national public-private initiative. The Partnership for Patients has ambitious nationwide goals: to reduce preventable hospital errors by 40 percent and to decrease hospital readmissions by 20 percent. The Community based care transitions program cctp was a key strategy in achieving these broader national healthcare improvement objectives.
Initiative Details of the Community Based Care Transitions Program
Launched in February 2012, the Community based care transitions program cctp was implemented over a five-year period. Participating community-based organizations (CBOs) were initially granted two-year agreements. These agreements had the potential for annual extensions throughout the program’s duration, contingent on performance.
Community-based organizations were central to the CCTP model. They utilized specialized care transition services to effectively manage the transitions of Medicare patients, with the ultimate goal of enhancing the quality of care they received during these critical periods. A total of up to $300 million in funding was allocated to the program from 2011 through 2015.
The financial structure of the CCTP involved paying CBOs an all-inclusive rate for each eligible patient discharge. This rate was calculated to cover the cost of care transition services provided directly to patients, as well as the expenses associated with implementing systemic improvements at the hospital level. Importantly, CBOs were compensated only once per eligible discharge within a 180-day period for any given Medicare beneficiary, ensuring efficient resource allocation.
Eligibility for the Community Based Care Transitions Program
It is important to note that the Community based care transitions program cctp is no longer accepting new participants. There are currently no plans to add future sites to the program.
The program was open to community-based organizations (CBOs), or acute care hospitals partnering with CBOs. Eligible entities were required to submit applications detailing their proposed care transition intervention strategies for Medicare beneficiaries in their communities who were identified as being at high risk of hospital readmission.
A key requirement for participating CBOs was the provision of care transition services across the entire continuum of care. They also needed to demonstrate established formal relationships with acute care hospitals and other relevant providers throughout this continuum.
Furthermore, eligible CBOs had to be physically located within the community they proposed to serve. They needed to be legally recognized entities capable of receiving payments for services rendered. A governing body with representation from various healthcare stakeholders, including consumer representation, was also a prerequisite. In the selection process, preference was given to Administration on Aging (AoA) grantees that were already providing care transition interventions in collaboration with multiple hospitals and practitioners. Additionally, organizations serving medically underserved populations, small communities, and rural areas were also prioritized.
For any inquiries or questions regarding the program, individuals were directed to contact: [email protected].
Evaluations and Further Information on CCTP
The effectiveness of the Community based care transitions program cctp has been rigorously evaluated. Evaluation reports are available to provide insights into the program’s impact and outcomes.
Evaluation Reports
Information on the latest evaluation report and prior evaluation reports can be accessed through the provided links, offering detailed analysis of the program’s performance.
Additional Information
For those seeking more in-depth information about the Community based care transitions program cctp, additional resources and materials are available. These resources can provide a more comprehensive understanding of the program’s design, implementation, and results.
