CMS data suggests almost 20% of hospitalized
Medicare patients are readmitted within 30 days of their discharge. 
This amounts to approximately 2.6 million
beneficiaries being affected and costs the Medicare program an estimated $26
billion every year. 
In an attempt to curb this expense, the CMS
Innovation Center established by the Affordable Care Act has created the
Community-Based Care Transition Program (CCTP).
The ACA has earmarked up to $500
million for the CCTP that was launched in 2011 and will run for 5 years.
The program starts with the basic principle that the
healthcare community should work together to improve quality of patient
care.
The goal is to ultimately reduce hospital
readmissions by a minimum of 20 % which would translate to a savings of $5.2 billion
a year. This represents a significantly
larger amount than the initial cost to CMS for the program.
Data for 2012 suggests the program
is already working by preventing an estimated 70,000 readmissions.
Enrolled participants, referred to
as Community-based organizations (CBOs) now numbering over 100, will work with
hospitals to coordinate patient care transitions. If you would like to see who is participating
in your area, you can select this link to access the CMS interactive map: http://innovation.cms.gov/initiatives/map/index.html?modelPass=CCTP
Care transitions as referred to in
this program, relate to hospital inpatients that are being discharged to their
home, a nursing home, or other care facility.
CBOs will use care transition services to identify risk factors that
produce readmissions and coordinate the necessary actions to lessen the effect
of those factors. 
CBOs will be required to provide:
Care transition services that begin no later than 24 hours
prior to discharge
Timely, culturally and linguistically competent
post-discharge education to patients
NOTE: This
education is crucial so that patients understand potential additional health
problems that may develop or a deteriorating condition.
Timely interactions between patients and post-acute and/or
outpatient providers
Patient centered self-management support and information
specific to the beneficiary’s condition
A comprehensive medication review and management
NOTE: This includes any appropriate counseling and
self-management support.
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. CBOs will only be paid once per eligible discharge in a
180-day period of time for any given beneficiary.
Performance and effectiveness of the
CBOs will be gauged by the evaluation contractor and the implementation and
monitoring contractor. Quality and
utilization measures will consist of 30-day all cause readmission rates, and
will also monitor 90-and 180-day readmission rates, mortality rates,
observation services, and emergency department visits. One major goal of the CCTP is to develop
effective approaches to care interventions that will improve the quality of
care while decreasing readmissions. This
transparency of the COB’s should ensure accurate evaluations of both successes
and shortcomings of this program.
Please follow this link to the CMS
site for full details on this program:
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