Improving Care Transitions
Care transitions refer to movement of patients from one health care provider or setting to another. For people living with serious and complex illnesses, transitions in setting of care (from hospital to home or nursing home, for example) are prone to errors. For example, one in five patients discharged from the hospital to home experience an adverse event within three weeks of discharge, when an adverse event is defined as an injury resulting from medical management rather than the underlying disease. The most common adverse events are medication related; they often can be avoided or mitigated. The rate for hospital readmissions among Medicare beneficiaries within 30 days of discharge, one indicator of the appropriateness of the transition process, is 20%, contributing to lower patient satisfaction and rising health care costs.
Learn more about the Roadmap to Better Care Transitions and Fewer Readmissions
The Community-based Care Transitions Program (CCTP)
A major component of the Partnership for Patients is the Community-based Care Transitions Program (CCTP). The Center for Medicare and Medicaid Services (CMS) has announced funding opportunities available for Community-based organizations (CBOs) partnering with acute-care hospitals to decrease preventable complications during a transition from one care setting to another.
Section 3026 of the Affordable Care Act
The CCTP program, which was 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. Community-based organizations will use care transition services to effectively manage Medicare patients’ transitions and improve their quality of care. The solicitation and application are available online at: http://go.cms.gov/caretransitions.
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,. In addition, an eligible 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.
What is required as part of the application?
Interested parties must submit a written proposal that addresses all of the evaluation selection criteria described in the solicitation on the CCTP web page at: http://go.cms.gov/caretransitions.
Applicants must:
- Identify community-specific root causes of readmissions and define their target population and strategies for identifying high risk patients
- Specify care transition interventions that will impact the root causes identified, which may include strategies for improving provider communications and improving patient activation
- Describe how care transition strategies will incorporate culturally appropriate and effective care transition beneficiary-centric approaches to ethnically diverse beneficiaries, and how other community and social supports and resources will be incorporated to enhance the beneficiaries’ post-hospitalization management outcomes
- Provide an implementation plan with milestones
- Provide a clear budget proposal, including a per eligible discharge rate reflecting direct costs for care transition services (this program differs from a grant program in that it will not pay for administrative overhead and infrastructure costs)
- Demonstrate prior experience, including successes and failures
What will participants do?
CBOs will be required to provide care transition services across the continuum of care, which may include at least one of the following features:
- Initiating care transition services no later than 24 hours prior to discharge (NOTE: Application should be specific as to the particular care transition services to be provided);
- Providing timely, culturally, and linguistically competent post-discharge education regarding symptoms that may indicate additional health problems or a deteriorating condition;
- Providing assistance to ensure timely and productive interactions between patients and post-acute and outpatient providers;
- Providing patient-centered self-management support and relevant information specific to the beneficiary’s condition; and
- Conducting comprehensive medication review and management (including, if appropriate, counseling and self-management support).
Applicants must address how they will align their care transition programs with care transition initiatives sponsored by other payers in their respective communities, including Medicaid, Medicare Advantage, and the private sector. All awardees must agree to and sign terms and conditions governing their participation in the program prior to their start in the program.
What resources and technical assistance will be provided?
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. For the convenience of applicants, a template for developing the budget is available on the CCTP webpage. The proposal should be designed to reduce readmissions, thereby reducing Medicare expenditures over the program period. The CBOs will submit invoices to CMS on a monthly basis to receive payment for care transition services initiated in the previous month. CBOs will not be paid a per eligible discharge rate more than once in a 180-day period for the same beneficiary under any circumstance.
Medicare Quality Improvement Organizations (QIOs) are providing assistance to communities, whether those just getting started in the work of care transitions improvement or those with previous experience that wish to apply to the CCTP. QIOs can help communities by: providing community-level readmissions data and analyzing trends, conducting a community-specific root cause analysis and helping communities select the appropriate interventions, helping to convene community partners, and providing other technical assistance on the CCTP application. A roster of the care transitions leads for each of the country’s 53 QIOs is available on the CCTP webpage. CMS encourages all applicants to seek assistance from their state’s QIO and learn more about how to improve care transitions through a comprehensive community effort at the QIO Integrating Care for Populations and Communities National Coordinating Center (NCC) at http://www.cfmc.org/integratingcare/.
How long will CMS accept applications?
As of April 12, 2011, CMS is accepting applicants and enrolling participants on a rolling basis as funding permits (estimated through at least June of 2012). The program will run for 5 years; however, applicants will be awarded 2-year agreements that may be extended on an annual basis for the remaining 3 years based on performance. The Secretary may extend or expand the program beyond the 5 years if the program demonstrates financial sustainability by reducing Medicare expenditures while maintaining or improving quality.
Fact Sheets: For the latest fact sheets and frequently asked questions, visit: http://go.cms.gov/caretransitions
Keys to a successful CCTP Application
Important facts about the CCTP
Why Care Transitions is good for:
- Beneficiaries
- Hospitals
- Community-based Organizations
- States
Posted on: November 18, 2011