The Affordable Care Act (ACA), officially known as the Patient Protection and Affordable Care Act, brought about significant changes to the healthcare landscape in the United States. Among its many provisions was the establishment of the Community-based Care Transitions Program (CCTP). This initiative was designed to test innovative models for enhancing care transitions for patients moving from hospitals to other healthcare settings. A key focus of the CCTP was to reduce hospital readmissions, particularly for high-risk Medicare beneficiaries.
The core objectives of the Affordable Care Act Community Based Care Transitions Program were multifaceted:
- Enhance Transitions: To improve the process of patients moving from inpatient hospital settings to other necessary care environments, such as home healthcare, skilled nursing facilities, or rehabilitation centers.
- Improve Care Quality: To ensure that patients receive high-quality care throughout their transition, leading to better health outcomes.
- Reduce Readmissions: To significantly decrease the rate of hospital readmissions for Medicare beneficiaries identified as being at high risk.
- Demonstrate Medicare Savings: To rigorously document and quantify measurable cost savings for the Medicare program resulting from the implemented interventions.
The CCTP Partners in Action
The Community-based Care Transitions Program was implemented through a network of 18 participating sites across the United States. These sites were instrumental in piloting and refining care transition models.
These partnerships were rolled out in several rounds, each bringing in new community-based organizations to contribute to the program’s goals.
Round 1 Partners: Announced November 18, 2011, these initial partners set the stage for the CCTP’s early implementation:
- Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio)
- Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona)
- The Southwest Ohio Community Care Transitions Collaborative (Ohio)
Round 2 Partners: Announced March 14, 2012, the second round expanded the program’s reach and incorporated diverse community settings:
- Elder Services of Worcester, Massachusetts (Massachusetts)
- Ohio AAA Region 8 (Ohio)
- Senior Alliance, Area Agency on Aging 1-C (Michigan)
- Western Pennsylvania Community Care Transition Program (Pennsylvania)
Round 3 Partners: Announced August 17, 2012, this round included organizations with a focus on varied patient populations and geographic locations:
- Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania)
- Catholic Charities of the Archdiocese of Chicago (Illinois)
- Mt. Sinai Hospital (New York)
- Somerville-Cambridge Elder Services (Massachusetts)
Round 4 Partners: Announced January 15, 2013, the fourth round further diversified the program’s partnerships:
- Aging & In-Home Services of Northeast Indiana (Indiana)
- Partners in Care Foundation (California)
- San Diego Care Transitions Partnership (California)
- Southern Alabama Regional Council on Aging (SARCOA) (Alabama)
Round 5 Partners: Announced March 07, 2013, the final round of partner organizations solidified the CCTP’s national presence:
- Kentucky Appalachian Transitions Services (Kentucky)
- Sun Health (Arizona)
- Top of Alabama Regional Council of Governments (Alabama)
Understanding the Need for Care Transitions
Care transitions are a critical point in a patient’s healthcare journey, occurring whenever an individual moves between different healthcare providers or settings. A significant issue within the U.S. healthcare system is the high rate of hospital readmissions. Alarmingly, nearly 20% of Medicare patients discharged from hospitals – approximately 2.6 million seniors annually – are readmitted within just 30 days. This concerning statistic translates to over $26 billion in costs each year for avoidable readmissions.
Traditionally, hospitals have been the primary focus of readmission reduction efforts, concentrating on factors within their direct control, such as the quality of inpatient care and discharge planning procedures. However, research indicates that a multitude of factors throughout the entire care continuum influence readmission rates. Identifying the key drivers of readmissions, both within hospitals and in downstream care settings, is crucial for developing effective interventions to reduce these numbers.
The Affordable Care Act Community Based Care Transitions Program directly addressed these gaps. It fostered a collaborative, community-centered approach to improve care quality, reduce healthcare costs, and enhance the patient experience during transitions. By encouraging partnerships between hospitals and community-based organizations, the CCTP aimed to create a more seamless and supportive transition process for patients.
Initiative Details and Implementation
Launched in February 2012, the CCTP was designed as a 5-year initiative. Participating community-based organizations (CBOs) were granted two-year agreements, with the possibility of annual extensions based on their performance and contribution to the program’s goals.
These CBOs played a pivotal role by delivering vital care transition services. These services were designed to effectively manage the transitions of Medicare patients, ensuring they received the necessary support and resources to maintain their health and well-being after discharge. The program had a substantial funding pool, with up to $300 million allocated between 2011 and 2015.
The financial model for the CCTP was designed to incentivize effective care transitions. CBOs received an all-inclusive payment per eligible discharge. This payment was based on the actual cost of providing care transition services at the individual patient level, as well as the costs associated with implementing systemic improvements at the hospital level to support better transitions. Importantly, to avoid duplication of services, CBOs were paid only once per eligible discharge within a 180-day period for each Medicare beneficiary.
Eligibility and Future Program Sites
It is important to note that the Affordable Care Act Community Based Care Transitions Program is not currently accepting new participants, and there are no plans to add future sites to the program.
The program was open to Community-Based Organizations (CBOs), or acute care hospitals collaborating with CBOs. Eligible applicants were required to submit proposals outlining their intended care transition interventions for Medicare beneficiaries in their communities who were identified as being at high risk of hospital readmission. A key requirement was that interested CBOs must have a proven track record of providing care transition services across the continuum of care and established formal partnerships with acute care hospitals and other relevant providers.
Further eligibility criteria included the CBO’s physical presence within the community they proposed to serve, their legal entity status allowing them to receive payments, and a governing body that included representation from diverse healthcare stakeholders, including patient advocates and consumers. In the selection process, preference was given to Administration on Aging (AoA) grantees, organizations that provided care transition interventions in partnership with multiple hospitals and practitioners, and entities serving medically underserved populations, small communities, and rural areas.
Program Evaluation and Impact
The Affordable Care Act Community Based Care Transitions Program included rigorous evaluations to assess its effectiveness and impact on care quality, readmission rates, and healthcare costs. These evaluations are critical for understanding the successes and challenges of the program and for informing future initiatives aimed at improving care transitions and patient outcomes.
While specific evaluation reports are available for review, the overarching goal of these assessments is to determine the extent to which the CCTP achieved its objectives of enhancing care transitions, improving care quality, reducing readmissions, and generating savings for the Medicare program. The findings from these evaluations provide valuable insights into best practices for community-based care transition programs and their potential to transform patient care and reduce the burden of hospital readmissions.
For further information or inquiries regarding the Affordable Care Act Community Based Care Transitions Program, interested parties were directed to contact: [email protected].
