Community-based Care Transitions Program

The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high risk beneficiaries, and to document measurable savings to the Medicare program.

The CCTP Partners

CCTP mappedClick anywhere on the map to view the interactive version

There are 102 participating sites involved in the Community-based Care Transitions Program. (List)
To view an interactive map of this Model, visit the Where Innovation is Happening page.

 

View all CCTP site summaries.

 

Round 1: The following partner organizations were announced on November 18, 2011:

  • Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio)
  • Atlanta Community-Based Care Transitions Program (Atlanta CCTP) (Georgia)
  • Council for Jewish Elderly (“CJE SeniorLife”) in Chicago, IL (Illinois)
  • Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona)
  • Elder Services of the Merrimack Valley, Inc. (Massachusetts & New Hampshire)
  • The Southern Maine Agency on Aging/Aging and Disability Resource Center (SMAA/ADRC) (Maine)
  • The Southwest Ohio Community Care Transitions Collaborative (Ohio)

Round 2: The following partner organizations were announced on March 14, 2012:

  • Advance Care Transitions (ACT), Marin County, California (California)
  • AgeOptions (Illinois)
  • Brooklyn Care Transition Coalition (New York)
  • Care Connection Aging and Disability Resource Center (Care Connection) (Texas)
  • CareLink (Arkansas)
  • Carondelet Chronic Care Navigation Program (Arizona)
  • Delaware County Office of Services for the Aging (Pennsylvania)
  • Elder Services of Berkshire County (Massachusetts)
  • Elder Services of Worcester, Massachusetts (Massachusetts)
  • El Paso, Texas Aging and Disability Resource Center (Texas)
  • Greater New Haven Coalition for Safe Transitions (Connecticut)
  • Lifespan of Greater Rochester Inc. (New York)
  • Michigan Area Agency on Aging 1-B (Michigan)
  • North Philadelphia Safety Net Partnership (Pennsylvania)
  • Ohio AAA Region 8 (Ohio)
  • P2 Collaborative of Western New York, Inc. (New York)
  • Pierce County, Washington Community Connections’ Aging and Disability Resources (Washington)
  • Southeast Washington Aging and Long Term Care (Washington)
  • St. John Providence Health System (Michigan)
  • Senior Alliance, Area Agency on Aging 1-C (Michigan)
  • Tompkins County, New York Office for the Aging (New York)
  • UniNet Healthcare Network (Nebraska)
  • Western Pennsylvania Community Care Transition Program (Pennsylvania)

Round 3: The following partner organizations were announced on August 17, 2012:

  • Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania)
  • Catholic Charities of the Archdiocese of Chicago (Illinois)
  • Connecticut Community Care, Inc. (CCCI) (Connecticut)
  • Eddy Visiting Nurse Association (New York)
  • Elder Options (Florida)
  • Greater Miami Coalition to Prevent Unnecessary Rehospitalizations (Florida)
  • Los Angeles Mid-City Integrated Care Collaborative (California)
  • Lower Rio Grande Valley Development Council (Texas)
  • Metropolitan Area Agency on Aging (Minnesota)
  • Mt. Sinai Hospital (New York)
  • New York Methodist Hospital (New York)
  • Northwest Triad Care Transitions Community Program (NTCTCP) (North Carolina)
  • Oceola-St. Cloud Community-based Care Transitions Coalition (Florida)
  • San Francisco Transitional Care Program (SFTCP) (California)
  • Somerville-Cambridge Elder Services (Massachusetts)
  • Visiting Nurse Service of Schenectady & Saratoga Counties, Inc. (VNS) (New York)
  • Whatcom Alliance for Healthcare Access (Washington)

Round 4: The following partner organizations were announced on January 15, 2013:

  • Access East Community-based Transitional Partnership (North Carolina)
  • AccessCare (North Carolina)
  • Aging & In-Home Services of Northeast Indiana (Indiana)
  • Aging and Long Term Care of Eastern Washington (Washington)
  • AltaMed Health Services Corporation (California)
  • Appalachian Community Transitions (ACTion) Project (Virginia)
  • Catholic Health Care Transitions Services, Inc. (Florida)
  • Central Savannah River Area Regional Commission (Georgia)
  • Central Texas Aging and Disability Resource Center (Texas)
  • Chattanooga Regional Medicare Community-based Care Transitions Program (Tennessee)
  • Community Care Connection (Ohio)
  • Community Research Resource Information Services for Seniors, Inc. (CHRIS) (Illinois)
  • The Coordinating Center (Maryland)
  • Denver Regional Council of Governments (Colorado)
  • East Central Ohio Community Care Transitions Coalition (Ohio)
  • Eastern Virginia Care Transitions Partnership (Virginia)
  • Glendale Memorial Hospital and Health Center (California)
  • Isabella Geriatric Center (New York)
  • Kansas City Quality Improvement Consortium, Inc. (Missouri)
  • Maui County Office on Aging (Hawaii)
  • Missoula Aging Services (Montana)
  • Multnomah County Aging and Disability Services (Oregon)
  • North Country Community-based Care Transitions Program (New York)
  • North East Ohio Coalition on Readmissions (Ohio)
  • Northeast Georgia Regional Commission (Georgia)
  • Partners in Care Foundation (California)
  • Queens Care Transition Collaborative (New York)
  • San Diego Care Transitions Partnership (California)
  • Siouxland Care Transitions (Iowa)
  • Southern Alabama Regional Council on Aging (SARCOA) (Alabama)
  • Three Rivers Planning & Development District (Mississippi)
  • Tri-County Aging Consortium (Michigan)
  • Upstate Care Transitions Coalition (South Carolina)
  • Ventura County Area Agency on Aging (California)
  • West Central Florida Area Agency on Aging (Florida)

Round 5: The following partner organizations were announced on March 07, 2013:

  • Area Agency on Aging of Southeast Texas (Texas)
  • Area Office on Aging of Northwestern Ohio, Inc. (Ohio)
  • Brewster Place (Kansas)
  • Capital Area Agency on Aging (CAAA) (Louisiana)
  • Carelink, Inc. (Rhode Island)
  • Central New Jersey Care Transition Program (New Jersey)
  • Community SeniorServ (California)
  • Deep East Texas Council of Governments (DETOG) Area Agency on Aging (AAA) (Texas)
  • Dominican Sisters Family Health Service, Inc. (New York)
  • Green River Area Development District (Kentucky)
  • Jewish Home for the Aging Geriatric Services Inc. (California)
  • Kentucky Appalachian Transitions Services (Kentucky)
  • LifeSpan Resources, Inc. (Indiana)
  • PSA 3 Area on Aging (Ohio)
  • Sonoma County Area Agency on Aging (California)
  • Sun Health (Arizona)
  • Top of Alabama Regional Council of Governments (Alabama)
  • Upper Arkansas Area Council of Governments (Colorado)
  • Valley Area Agency on Aging (Michigan)
  • York County Area Agency on Aging (Pennsylvania)

Background

Care transitions occur when a patient moves from one health care provider or setting to another. Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year. Hospitals have traditionally served as the focal point of efforts to reduce readmissions by focusing on those components that they are directly responsible for, including the quality of care during the hospitalization and the discharge planning process. However, it is clear that there are multiple factors along the care continuum that impact readmissions, and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions.

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

The CCTP is part of the Partnership for Patients, a nationwide public-private partnership that aims to reduce preventative errors in hospitals by 40 percent and reduce hospital readmissions by 20 percent,

Initiative Details

The CCTP, launched in 2011, will run for 5 years. Participants will be awarded two-year agreements that may be extended annually through the duration of the program based on performance.

Community-based organizations (CBOs) will use care transition services to effectively manage Medicare patients' transitions and improve their quality of care. Up to $500 million in total funding is available for 2011 through 2015. The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level. CBOs will only be paid once per eligible discharge in a 180-day period of time for any given beneficiary.

Eligibility and How to Apply

CBOs, or acute care hospitals that partner with CBOs, are eligible to submit an application describing the proposed care transition intervention(s) for Medicare beneficiaries in their communities who are at high risk of readmission. Interested CBOs must provide care transition services across the continuum of care and have formal relationships with acute care hospitals and other providers along the continuum of care.

An interested CBO must be physically located in the community it proposes to serve, must be a legal entity that can accept payment for services, and have a governing body with representation from multiple healthcare stakeholders including consumers. In selecting CBOs, preference will be given to Administration on Aging (AoA) grantees that provide care transition interventions in conjunction with multiple hospitals and practitioners and/or entities that provide services to medically-underserved populations, small communities, and rural areas.

CBOs interested in applying for the CCTP may wish to contact their Medicare Quality Improvement Organization (QIO). QIOs can help communities by providing community-level readmissions data and analyzing trends, conducting a community-specific root cause analysis, helping communities select the appropriate interventions, helping to convene community partners, and providing other technical assistance on the CCTP application. CMS encourages communities wishing to apply to the CCTP to learn more at http://www.cfmc.org/integratingcare and seek assistance from their QIO directly by accessing the care transitions contacts (PDF) resource provided by cfmc.org.

Application Information. The proposal should be designed to reduce readmissions, thereby reducing Medicare expenditures over the program period. In addition to the solicitation and application, a template for developing the budget is available:

Please send all proposals (regular mail and commercial delivery) to the following address:

Center for Medicare & Medicaid Innovation
Attn: Juliana Tiongson
Mail Stop: WB 06-05
7500 Security Blvd.
Baltimore, MD 21244-1850

Upcoming Panel Review Dates

Applications are accepted on a rolling basis. The final panel review of applications will occur on September 20, 2012. Applications must be received by September 3rd to be considered for this review Future panels may be announced as funding permits.

Additional Information

For more information on CTTP, including archived files, visit the CMS.gov CCTP page.



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