1. CMS National Conference on Care Transitions December 3, 2010 1

2. Community-based Care Transitions Program (CCTP) Juliana R. Tiongson Social Science Research Analyst Centers for Medicare and Medicaid Services Office of Research, Development and Information 2

3. 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. 3

4. 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 4

5. 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 5

6. 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. 6

7. 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 7

8. 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 8

9. 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

10. 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

11. 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/i temdetail.asp?itemID=CMS1239313 http://www.cms.gov/DemoProjectsEvalRpts/MD/i temdetail.asp?itemID=CMS1239313 Please direct questions to CareTransitions@cms.hhs.gov CareTransitions@cms.hhs.gov