The Community-based Care Transitions Program (CCTP) was established under Section 3026 of the Affordable Care Act to pilot innovative approaches for improving patient transitions from hospitals to various post-hospital settings. This initiative specifically aimed to decrease hospital readmissions among high-risk Medicare beneficiaries. The core objectives of the CCTP were multifaceted: to facilitate smoother transitions for beneficiaries moving from inpatient hospital environments to other care settings, to elevate the overall quality of care received, to achieve a significant reduction in readmission rates for high-risk patient populations, and to demonstrate tangible cost savings for the Medicare program.
CCTP Partner Organizations Across the Nation
The Community-based Care Transitions Program engaged a diverse network of 18 participating organizations across the United States. These sites were selected through multiple rounds of announcements, reflecting a phased approach to program implementation and expansion.
Round 1 CCTP Partners
Announced November 18, 2011:
- Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio): Focused on serving the aging population in the Akron/Canton region, providing essential care transition services.
- Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona): Covering Maricopa County, this agency aimed to improve care transitions for seniors in a large metropolitan area.
- The Southwest Ohio Community Care Transitions Collaborative (Ohio): A collaborative effort in Southwest Ohio designed to enhance care coordination and reduce readmissions in the region.
Round 2 CCTP Partners
Announced March 14, 2012:
- Elder Services of Worcester, Massachusetts (Massachusetts): Serving the Worcester area, this organization focused on the unique needs of elderly patients during care transitions.
- Ohio AAA Region 8 (Ohio): Expanding CCTP’s reach in Ohio, Region 8 aimed to implement effective transition models in their service area.
- Senior Alliance, Area Agency on Aging 1-C (Michigan): Serving Southeastern Michigan, this agency worked to improve care transitions for seniors in the Detroit metropolitan area.
- Western Pennsylvania Community Care Transition Program (Pennsylvania): Focused on Western Pennsylvania, this program aimed to address the challenges of care transitions in a diverse geographical region.
Round 3 CCTP Partners
Announced August 17, 2012:
- Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania): Serving Allegheny County, this agency concentrated on integrating care transitions into existing human services frameworks.
- Catholic Charities of the Archdiocese of Chicago (Illinois): Utilizing a community-based approach through Catholic Charities to improve care transitions in the Chicago metropolitan area.
- Mt. Sinai Hospital (New York): Representing a hospital-based approach, Mt. Sinai aimed to enhance care transitions within a major New York City medical center.
- Somerville-Cambridge Elder Services (Massachusetts): Serving the Somerville-Cambridge area, this organization focused on delivering tailored care transition services for the elderly population.
Round 4 CCTP Partners
Announced January 15, 2013:
- Aging & In-Home Services of Northeast Indiana (Indiana): Addressing care transitions in Northeast Indiana through in-home and community-based services for the aging population.
- Partners in Care Foundation (California): Serving California, this foundation focused on innovative care models and partnerships to improve patient transitions across diverse communities.
- San Diego Care Transitions Partnership (California): A regional partnership in San Diego dedicated to improving care coordination and reducing hospital readmissions through collaborative strategies.
- Southern Alabama Regional Council on Aging (SARCOA) (Alabama): Focused on the Southern Alabama region, SARCOA aimed to address the specific care transition needs of rural and underserved populations.
Round 5 CCTP Partners
Announced March 07, 2013:
- Kentucky Appalachian Transitions Services (Kentucky): Addressing the unique challenges of care transitions in the Appalachian region of Kentucky, focusing on rural healthcare access.
- Sun Health (Arizona): Serving Arizona, Sun Health implemented comprehensive care transition programs to improve patient outcomes and reduce readmissions within their network.
- Top of Alabama Regional Council of Governments (Alabama): Covering Northern Alabama, this regional council aimed to enhance care transitions through inter-agency collaboration and community-based solutions.
The Critical Need for Community-Based Care Transitions
Care transitions, the process of moving patients between different healthcare providers or settings, are a particularly vulnerable point in the continuum of care. Alarmingly, nearly 20% of Medicare patients discharged from a hospital – approximately 2.6 million senior citizens – are readmitted within just 30 days. This concerning rate of readmission not only signifies potential gaps in care quality but also carries a substantial financial burden, costing the healthcare system over $26 billion annually.
Historically, efforts to tackle hospital readmissions have been largely hospital-centric. These initiatives have primarily concentrated on factors within the hospital’s direct control, such as the quality of inpatient care and the effectiveness of discharge planning procedures. However, a broader perspective reveals that numerous elements across the entire care spectrum significantly influence readmission rates. Identifying the key factors driving readmissions, both within the hospital and in subsequent care settings, is a crucial first step towards implementing targeted interventions that can effectively reduce readmissions and improve patient outcomes.
The CCTP was strategically designed to address these systemic shortcomings. It promoted a collaborative, community-wide approach, encouraging diverse stakeholders to unite and work synergistically. This collaborative spirit was intended to drive improvements in care quality, achieve cost efficiencies, and ultimately enhance the overall patient experience during and after hospital discharge.
The CCTP was a key component of the broader Partnership for Patients initiative. This nationwide public-private partnership has ambitious goals: to reduce preventable medical errors in hospitals by 40 percent and to decrease hospital readmissions by 20 percent. The CCTP directly contributed to the readmission reduction goal through its targeted community-based interventions.
Initiative Details and Program Structure
Launched in February 2012, the Community-based Care Transitions Program was implemented over a five-year period. Participating organizations were initially granted two-year agreements, with the possibility of annual extensions based on demonstrated performance and adherence to program goals.
Community-based organizations (CBOs) were central to the CCTP model. These organizations were tasked with delivering specialized care transition services aimed at effectively managing Medicare patients’ transitions and enhancing the quality of care they received during these critical junctures. A significant financial commitment of up to $300 million in total funding was allocated for the program, spanning from 2011 through 2015.
The CBOs participating in the CCTP were compensated through an all-inclusive per-discharge rate. This rate was calculated to reflect the costs associated with providing comprehensive care transition services at the individual patient level, as well as the expenses related to implementing systemic improvements at the hospital level to support better transitions. Importantly, to ensure efficient resource utilization, CBOs were only compensated once per eligible discharge for any given beneficiary within a 180-day period. This payment structure incentivized effective and efficient care transition management, avoiding duplicative payments for the same patient within a short timeframe.
Eligibility Criteria for CCTP Participation
It is important to note that the Community-based Care Transitions Program is not currently accepting new participants. There are no plans to add further sites to the program beyond those already selected.
The eligibility criteria for organizations seeking to participate in the CCTP were specifically defined to ensure that participating entities were well-positioned to deliver effective care transition services. Eligible applicants included Community-Based Organizations (CBOs) or acute care hospitals that partnered with CBOs. Interested applicants were required to submit a detailed proposal outlining their planned care transition intervention(s) targeting Medicare beneficiaries within their communities who were identified as being at high risk of hospital readmission.
A key requirement for CBO applicants was the demonstrated capacity to provide care transition services across the entire continuum of care. This included having established formal relationships and collaborative agreements with acute care hospitals and other relevant providers operating along the care continuum.
Furthermore, to ensure community relevance and local expertise, interested 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 and managing payments for services rendered. A crucial aspect of eligibility was the requirement for a governing body that included representation from a diverse range of healthcare stakeholders, including patient or consumer representation, ensuring a patient-centered approach to program design and implementation.
In the selection process, preference was given to Administration on Aging (AoA) grantees. Priority was also given to organizations that proposed to deliver care transition interventions in collaboration with multiple hospitals and practitioners and/or those that provided services to medically underserved populations, small communities, and rural areas, reflecting a commitment to equitable access to care transition support.
For any remaining inquiries or questions regarding the Community-based Care Transitions Program, interested parties were directed to contact the program via email at: [email protected].
