1. 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 1

2. 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. The program will run for 5 years with the possibility of expansion beyond 2015. 2

3. 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 3

4. 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 4

5. 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. 5

6. 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. 6

7. Preferences Preference will be given to proposals that : – include participation in a program administered by the AoA to provide concurrent care transition interventions with multiple hospitals and practitioners – provide services to medically- underserved populations, small communities and rural areas

8. Considerations Applicants must address: – how they will align their care transition programs with care transition initiatives sponsored by other payers in their respective communities – how they will work with accountable care organizations and medical homes that develop in their communities

9. Additional Considerations Consideration will be given to hospitals whose 30-day readmission rate on at least two of the three hospital compare measures (AMI, HF, PNEU) falls in the fourth quartile for its state. Applicants are required to complete a root cause analysis

10. Frequently Asked Questions Does a coalition representing a collaboration of community healthcare providers (medical centers, FQHCs, health plans, educational leaders and local government) qualify as a CBO? What is required in order to meet the requirement of “multiple health care stakeholders?”

11. Frequently Asked Questions We have a network of providers that have agreed to participate in this program. What kind of legal entity is required to meet the definition of CBO? Does a home health provider qualify as a CBO? What is involved in a root cause analysis?

12. Frequently Asked Questions Does a health system or integrated delivery system qualify as a CBO? Does a QIO qualify as a CBO? Does an advisory board with consumer representation suffice as the governing body required of CBOs? How about a steering committee?

13. Frequently Asked Questions Would a University working in partnership with an acute care hospital, and CBO be eligible to apply to be the recipient and lead organization for the CCTP? Can my organization participate in the CCTP if we are already participating in another demonstration or pilot?

14. Frequently Asked Questions Is participation in the CCTP limited to the acute care hospitals listed in the high readmission hospital file posted on the program webpage? What is the significance of the hospitals in bold type above the dotted line in the high readmission hospital file? What is the significance of the numbers 2 or 3?

15. Conclusion A program solicitation will be posted shortly in the Federal Register at which time applications will be accepted and reviewed on a rolling basis 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