CMS National Conference on Care Transitions

December 3, 2010

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Community-based Care Transitions Program (CCTP)

Juliana R. TiongsonSocial Science Research Analyst

Centers for Medicare and Medicaid Services

Office of Research, Development and Information

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The Community–based Care Transitions Program

• The CCTP, mandated by section 3026 of the Affordable Care Act, provides funding to test models for improving care transitions for high risk Medicare beneficiaries.

• Increasing rates of avoidable hospital readmissions will result in negative health outcomes for Medicare beneficiaries impacting their levels of safety and quality of care.

• The CCTP seeks to correct these deficiencies by encouraging communities to come together and work together to improve quality, reduce cost, and improve patient experience.

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Program Goals

• Improve transitions of beneficiaries from the inpatient hospital setting to other care settings

• Improve quality of care• Reduce readmissions for high risk

beneficiaries• Document measureable savings to the

Medicare program

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Eligible Applicants

• Are statutorily defined as:−Acute Care Hospitals with high

readmission rates in partnership with a community based organization

−Community-based organizations (CBOs) that provide care transition services

• There must be a partnership between the acute care hospitals and the CBO

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Definition of CBO• Community-based organizations that

provide care transition services across the continuum of care through arrangements with subsection (d) hospitals

−Whose governing bodies include sufficient representation of multiple health care stakeholders, including consumers.

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Key Points

• CBOs will use care transition services to effectively manage transitions and report process and outcome measures on their results.

• Applicants will not be compensated for services already required through the discharge planning process under the Social Security Act and stipulated in the CMS Conditions of Participation.

• Applicants will be required to participate in ongoing learning collaboratives

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Requirements

– Initiating care transition services no later than 24 hours prior to discharge

– Providing timely, culturally, and linguistically competent post-discharge education

– Ensure timely and productive interactions between patients and providers

– Medication review and management– Patient centered self-management support

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Preferences

• Preference must be given to applications that :– include participation in a program

administered by the AoA– provide services to medically-

underserved populations, small communities and rural areas

• Physician group practices

Application Guidance

– Applicants are required to complete a root cause analysis

– The proposals must specify how the root causes will be addressed

– how they will work with accountable care organizations and medical homes

– how they will align their care transition programs

Conclusion

• A program solicitation will be announced shortly in the Federal Register

• Please visit our program website for daily updates on program status at http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313

• Please direct questions to CareTransitions@cms.hhs.gov