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Mentor moment: Applying for the Community-Based Care Transitions Program

Case Management Weekly, January 5, 2011

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Assuming Republicans in Congress don’t make good on their promise to defund and repeal the Affordable Care Act, 2011 will bring new initiatives designed to improve quality of care. One such initiative is the Community-Based Care Transitions Program (CCTP) demonstration project, which will fund efforts to improve transitions from hospitals and reduce readmissions.

Acute care hospitals with high readmission rates can claim a piece of the $500 million allocated to the program if they can demonstrate a relationship with community-based organizations. Selected hospitals will be expected to report process and outcome measures on their results and participate in an ongoing learning collaborative. CMS also expects participants to perform the following tasks:

• Initiate care transition services no later than 24 hours before discharge
• Provide timely, culturally, and linguistically competent post-discharge education
• Ensure timely and productive interactions between patients and providers
• Review and manage patient medications
• Support patient-centered self-management

Linda Magno, Director of the Medicare Demonstrations Program Group at CMS said in early December 2010 that CMS would release a solicitation of applications by the end of the year, but it failed to do so. However, that doesn’t mean interested facilities shouldn’t begin to gather the necessary application information.

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