Transitions Of Care Programs are designed to ensure patients receive coordinated and seamless care as they move between different healthcare settings, such as from a hospital to home or to a skilled nursing facility. These programs are crucial in improving patient outcomes, reducing hospital readmissions, and enhancing the overall quality of healthcare. One notable example of such an initiative is the Community-based Care Transitions Program (CCTP), established under Section 3026 of the Affordable Care Act. This program aimed to test various models for enhancing care transitions and decreasing readmissions, specifically for Medicare beneficiaries at high risk. The primary objectives of the CCTP were to facilitate smoother transitions for beneficiaries from hospitals to other care environments, elevate the quality of care provided, lower readmission rates among high-risk individuals, and demonstrate measurable cost savings for the Medicare system.
The Network of CCTP Partners
The Community-based Care Transitions Program (CCTP) was implemented through a network of 18 participating sites across the United States. These sites, comprising diverse healthcare organizations, worked collaboratively to test and refine strategies for improving transitions of care programs within their communities.
Round 1 Partners: Announced on November 18, 2011, the initial group of partners included:
- Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio): Focused on delivering community-based services to support seniors in the Akron and Canton areas, facilitating smoother transitions and reducing hospital readmissions.
- Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona): Serving the Phoenix metropolitan area, this agency aimed to improve care coordination for older adults transitioning from hospital settings back to their homes or community living.
- The Southwest Ohio Community Care Transitions Collaborative (Ohio): A regional collaborative designed to enhance care transitions across multiple healthcare providers in Southwest Ohio, aiming for a unified approach to reduce readmissions.
Round 2 Partners: Announced on March 14, 2012, the second round expanded the program’s reach with the following organizations:
- Elder Services of Worcester, Massachusetts (Massachusetts): Providing comprehensive support services for elders in Central Massachusetts, including specialized programs for care transitions to ensure continuity of care.
- Ohio AAA Region 8 (Ohio): Covering a different region of Ohio, this Area Agency on Aging focused on tailoring care transition models to meet the specific needs of their local communities.
- Senior Alliance, Area Agency on Aging 1-C (Michigan): Serving Wayne County, Michigan, this agency worked to improve transitions of care for seniors in the Detroit metropolitan area, addressing urban healthcare challenges.
- Western Pennsylvania Community Care Transition Program (Pennsylvania): A regional initiative covering Western Pennsylvania, aimed at fostering collaboration among healthcare providers to enhance patient transitions across the region.
Round 3 Partners: Announced on August 17, 2012, further broadening the program’s scope:
- Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania): Serving the Pittsburgh area, this agency focused on leveraging county resources to support effective care transitions for at-risk Medicare beneficiaries.
- Catholic Charities of the Archdiocese of Chicago (Illinois): Bringing a community-based approach to care transitions in the Chicago metropolitan area, utilizing their extensive network to support vulnerable populations.
- Mt. Sinai Hospital (New York): Representing a major urban hospital in New York City, Mt. Sinai aimed to integrate community-based care transition services within a large hospital system to improve discharge processes.
- Somerville-Cambridge Elder Services (Massachusetts): Serving the communities near Boston, this organization specialized in delivering elder care services, including programs focused on transitions of care and reducing hospital readmissions.
Round 4 Partners: Announced on January 15, 2013, continuing the program’s expansion:
- Aging & In-Home Services of Northeast Indiana (Indiana): Serving a large region in Northeast Indiana, this agency focused on delivering in-home and community-based services to support seniors during care transitions.
- Partners in Care Foundation (California): Based in California, this foundation focused on innovative approaches to care management and care transitions, working with diverse healthcare providers across the state.
- San Diego Care Transitions Partnership (California): A regional partnership in San Diego County, aimed at creating a coordinated system for care transitions to improve patient flow and reduce readmissions across the region.
- Southern Alabama Regional Council on Aging (SARCOA) (Alabama): Serving Southern Alabama, SARCOA addressed the unique challenges of rural healthcare delivery in care transitions, focusing on improving access to services for seniors in less populated areas.
Round 5 Partners: Announced on March 07, 2013, completing the partner network:
- Kentucky Appalachian Transitions Services (Kentucky): Addressing the specific healthcare needs of the Appalachian region in Kentucky, this program focused on overcoming geographical barriers in delivering effective care transition services.
- Sun Health (Arizona): Based in Arizona, Sun Health brought a focus on wellness and healthy aging to their care transition programs, aiming to empower seniors to manage their health effectively after hospital discharge.
- Top of Alabama Regional Council of Governments (Alabama): Serving Northern Alabama, this regional council focused on coordinating care transition services across multiple counties, addressing the needs of both urban and rural communities in their region.
The Importance of Care Transitions
Care transitions are pivotal moments in a patient’s healthcare journey, occurring whenever an individual moves between different healthcare providers or settings. A significant issue within the healthcare system is the high rate of hospital readmissions. Alarmingly, nearly 20% of Medicare patients discharged from hospitals—approximately 2.6 million seniors—are readmitted within just 30 days. This concerning trend not only impacts patient well-being but also carries a substantial financial burden, costing over $26 billion annually. Traditionally, hospitals have been the primary focus of efforts to decrease readmissions, concentrating on aspects within their direct control such as the quality of in-hospital care and discharge planning. However, it’s now understood that numerous factors throughout the entire continuum of care influence readmission rates. Identifying the key factors contributing to readmissions for a hospital and its network of downstream providers is a critical initial step in implementing targeted and effective interventions to reduce these rates and improve patient outcomes within transitions of care programs.
The CCTP initiative directly addressed these gaps by fostering community collaboration and integrated approaches to enhance care quality, reduce healthcare costs, and improve the overall patient experience during transitions of care. By encouraging different community stakeholders to work together, the program aimed to create a more cohesive and supportive healthcare ecosystem for patients navigating care transitions.
CCTP was also a key component of the broader Partnership for Patients initiative, a national public-private collaboration. The Partnership for Patients aimed to achieve significant improvements in patient safety nationwide, targeting a 40 percent reduction in preventable hospital errors and a 20 percent decrease in hospital readmissions. The CCTP program contributed directly to these national goals by focusing on improving transitions of care and reducing unnecessary hospital readmissions.
Program Details and Implementation
Launched in February 2012, the Community-based Care Transitions Program (CCTP) was structured as a 5-year initiative. Participating community-based organizations (CBOs) were initially granted two-year agreements, with the possibility of annual extensions based on their performance and continued program funding. These CBOs played a central role in delivering enhanced care transition services, effectively managing the transitions of Medicare patients and striving to improve their overall quality of care during these critical junctures. A total of up to $300 million in funding was allocated for the CCTP program spanning from 2011 through 2015, demonstrating a significant investment in improving transitions of care programs nationwide.
The financial model for CBO participation involved an all-inclusive per-discharge rate. This payment structure was designed to cover both the direct costs of providing care transition services at the patient level and the expenses associated with implementing systemic improvements at the hospital level. To ensure efficient use of resources, CBOs were compensated only once per eligible patient discharge within a 180-day period. This payment model encouraged CBOs to focus on delivering comprehensive and effective care transition services that would have a lasting impact on reducing readmissions and improving patient outcomes.
Eligibility and Future Opportunities
It is important to note that the Community-based Care Transitions Program (CCTP) is not currently accepting new participants. As of now, there are no plans to expand the program with additional sites in the future.
The eligibility criteria for CCTP participation were specifically designed to engage community-based organizations (CBOs) or partnerships between acute care hospitals and CBOs. Eligible applicants were required to submit detailed proposals outlining their planned care transition interventions for Medicare beneficiaries within their communities who were identified as being at high risk of hospital readmission. A key requirement for participating CBOs was their demonstrated capacity to provide care transition services across the entire continuum of care. Furthermore, they needed to have established formal working relationships with acute care hospitals and other healthcare providers throughout this continuum.
To be eligible, CBOs were required to be physically located within the community they proposed to serve and had to be legally structured entities capable of receiving payments for services rendered. Additionally, they needed to have a governing body that included representation from a diverse range of healthcare stakeholders, including patient or consumer representatives, ensuring a broad perspective in program governance. In the selection process, preference was given to Administration on Aging (AoA) grantees who were already providing care transition interventions in collaboration with multiple hospitals and practitioners. Priority was also given to entities that provided services to medically underserved populations, small communities, and rural areas, reflecting a commitment to addressing health equity through transitions of care programs.
For any inquiries or further information, the program directed interested parties to contact: [email protected].
Program Evaluations and Impact Assessment
Evaluation Reports
The original article mentions “Latest Evaluation Report” and “Prior Evaluation Report” but does not link to them or provide any details. To enhance this section, ideally, links to these reports or summaries of their findings should be included to provide readers with evidence of the program’s effectiveness and impact on transitions of care. Including key findings from these evaluations would significantly strengthen the article by demonstrating the outcomes and lessons learned from the CCTP initiative.
Additional Information
This section in the original article is very brief and doesn’t offer specific additional resources. To improve this, consider adding links to related resources such as:
- Publications or articles discussing the outcomes of the CCTP program.
- Information on best practices in transitions of care programs.
- Resources from organizations involved in care transitions and readmission reduction.
- Links to the Partnership for Patients website for broader context.
By expanding on the evaluation and additional information sections, the article can become a more comprehensive and valuable resource for readers interested in transitions of care programs and the CCTP initiative.
