The healthcare system is complex, and the journey for patients doesn’t end when they leave the hospital. A critical aspect of effective healthcare is ensuring smooth and safe transitions for patients as they move from hospital inpatient settings to other care environments. Recognizing this need, the Affordable Care Act established the Community-based Care Transitions Program (CCTP). This initiative was designed to test innovative models aimed at improving these crucial care transitions and significantly reducing hospital readmissions, particularly for high-risk Medicare beneficiaries. The overarching goals of the CCTP were to enhance the transition experience for beneficiaries moving from hospitals to various post-acute care settings, elevate the overall quality of care provided, achieve a measurable reduction in readmission rates for those at highest risk, and ultimately, generate demonstrable cost savings for the Medicare program.
CCTP Partner Organizations Across the Nation
The Community-based Care Transitions Program was implemented through a network of 18 participating sites across the United States. These sites were selected over five rounds of announcements, each representing a commitment to improving care transitions within their communities. Below are the organizations that partnered with the CCTP, demonstrating a nationwide effort to address this critical healthcare challenge.
Round 1 Partners (Announced November 18, 2011):
- Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio) – Serving communities in the Akron and Canton areas to improve care for seniors.
- Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona) – Focusing on care transition improvements within Maricopa County.
- The Southwest Ohio Community Care Transitions Collaborative (Ohio) – A collaborative effort to enhance care transitions in Southwest Ohio.
Round 2 Partners (Announced March 14, 2012):
- Elder Services of Worcester, Massachusetts (Massachusetts) – Providing enhanced transition services to elders in the Worcester area.
- Ohio AAA Region 8 (Ohio) – Expanding care transition programs across Ohio Region 8.
- Senior Alliance, Area Agency on Aging 1-C (Michigan) – Serving seniors in Michigan’s Area Agency on Aging 1-C region with improved care transitions.
- Western Pennsylvania Community Care Transition Program (Pennsylvania) – A regional program dedicated to better care transitions in Western Pennsylvania.
Round 3 Partners (Announced August 17, 2012):
- Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania) – Focusing on Allegheny County to improve human services and care for aging populations.
- Catholic Charities of the Archdiocese of Chicago (Illinois) – Leveraging community resources to improve care transitions in the Chicago area.
- Mt. Sinai Hospital (New York) – Integrating care transition programs within a major New York hospital system.
- Somerville-Cambridge Elder Services (Massachusetts) – Serving elder populations in the Somerville and Cambridge areas with specialized transition programs.
Round 4 Partners (Announced January 15, 2013):
- Aging & In-Home Services of Northeast Indiana (Indiana) – Delivering in-home and aging services with a focus on care transitions in Northeast Indiana.
- Partners in Care Foundation (California) – Implementing innovative care models in California, including enhanced transition programs.
- San Diego Care Transitions Partnership (California) – A partnership focused on improving care transitions specifically in the San Diego region.
- Southern Alabama Regional Council on Aging (SARCOA) (Alabama) – Addressing the needs of seniors in Southern Alabama through regional aging council initiatives.
Round 5 Partners (Announced March 07, 2013):
- Kentucky Appalachian Transitions Services (Kentucky) – Providing specialized transition services within the Appalachian region of Kentucky.
- Sun Health (Arizona) – Integrating comprehensive care transition models within the Sun Health network in Arizona.
- Top of Alabama Regional Council of Governments (Alabama) – Focusing on regional collaboration to improve care transitions in Northern Alabama.
The Critical Need for Effective Care Transitions
Care transitions are a pivotal point in a patient’s healthcare journey, occurring whenever an individual moves between different healthcare providers or settings. The statistics highlight the urgency for improvement: alarmingly, nearly one in five Medicare patients discharged from a hospital – approximately 2.6 million seniors annually – are readmitted within just 30 days. This revolving door of readmissions not only impacts patient well-being but also carries a staggering financial burden, costing over $26 billion each year.
Traditionally, hospitals have been at the forefront of efforts to reduce readmissions, concentrating primarily on factors within their direct control, such as the quality of inpatient care and discharge planning processes. However, the reality is that numerous factors across the entire care continuum contribute to readmissions. Identifying the key drivers specific to a hospital and its network of downstream care providers is the essential first step. This understanding allows for the implementation of targeted and effective interventions aimed at truly reducing readmission rates and improving patient outcomes.
The CCTP was strategically designed to address these systemic gaps. It fostered a collaborative, community-wide approach, encouraging diverse stakeholders to unite and work synergistically. This unified effort aimed to not only enhance the quality of care transitions but also to simultaneously reduce healthcare costs and significantly improve the overall patient experience during these critical junctures. The CCTP initiative is a key component of the broader Partnership for Patients, a national public-private collaboration with ambitious goals: to decrease preventable hospital errors by 40 percent and to lower hospital readmissions by 20 percent across the nation.
Initiative Details and Program Structure
Launched in February 2012, the CCTP was structured as a five-year program, emphasizing sustained improvement in care transition processes. Participating organizations were initially granted two-year agreements, with the potential for annual extensions based on demonstrated performance and impact.
A cornerstone of the CCTP was the utilization of Community-Based Organizations (CBOs). These organizations played a central role in delivering comprehensive care transition services, effectively managing the transitions for Medicare patients and striving to enhance their overall quality of care. A total funding pool of up to $300 million was allocated for the program spanning from 2011 through 2015, reflecting a significant investment in improving care transitions.
The financial model for CBOs within the CCTP was based on an all-inclusive rate per eligible discharge. This rate was carefully calculated to reflect the actual cost of providing patient-level care transition services and implementing essential systemic changes at the hospital level to support better transitions. Importantly, to ensure efficient resource utilization, CBOs were compensated only once per eligible discharge within a 180-day period for any given Medicare beneficiary.
Eligibility and Future Program Expansion
Currently, there are no provisions for adding new sites to the Community-based Care Transitions Program. The program’s structure was designed to operate with the initial cohort of selected community-based organizations.
Eligibility to participate in the CCTP was initially open to Community-Based Organizations (CBOs), or acute care hospitals partnering directly with CBOs. Interested applicants were required to submit detailed proposals outlining their planned care transition interventions tailored for Medicare beneficiaries within their communities who were identified as being at high risk for hospital readmission. A prerequisite for CBO participation was the demonstrated capacity to provide care transition services across the entire continuum of care. Furthermore, CBOs were required to have established formal working relationships with acute care hospitals and other relevant providers operating along the continuum of care to ensure seamless coordination.
To be eligible, a CBO needed to be physically based within the community it proposed to serve, be a legally recognized entity capable of receiving payments for services rendered, and maintain a governing body that included representation from a diverse array of healthcare stakeholders, including patient or consumer advocates. In the selection process, preference was given to Administration on Aging (AoA) grantees. Priority was also given to organizations that demonstrated the ability to provide care transition interventions in collaboration with multiple hospitals and practitioners, and/or those entities that delivered services to medically underserved populations, smaller communities, and rural areas, addressing critical disparities in healthcare access and quality.
For any inquiries or questions regarding the program, individuals were directed to contact the designated email address: [email protected].
Program Evaluation and Further Information
[Latest Evaluation Report]
[Prior Evaluation Report]
[Additional Information]
(Note: The links above “[Latest Evaluation Report]”, “[Prior Evaluation Report]”, and “[Additional Information]” are placeholders as in the original article and would ideally link to the relevant reports and information pages when available.)
