CMSA Today - Issue 5, 2014 - (Page 14)

CCTP The Community-Based Care Transitions Program Improving Care Transitions from Hospitals to Other Settings of Care BY AMY GOTWALS AND LINDSAY PUNZENBERGER T he Community-Based Care Transitions Program (CCTP) was created by Affordable Care Act and provides funding to local communitybased organizations (CBOs) to test models for improving care transitions from hospitals to other settings of care. The role of CBOs is critical, as the program creates a bridge between acute care and home and community-based care. In creating the program, Congress recognized the failures of our current system to adequately care for patients moving between care settings, which create serious patient safety, quality of care, and health outcome concerns. In addition, poor transitions in care also lead to significant financial burdens for patients, payers, and taxpayers. Nearly one in five Medicare patients discharged from a hospital - approximately 2.6 million seniors - are readmitted within 30 days, at a cost of over $26 billion every year. Of those additional expenditures, an estimated $12 billion was spent on readmissions that could have been prevented.1 There are many evidence-based care transitions interventions that have led to documented improvements in both health outcomes and reduction in costs to the health care system.2 CCTP seeks to foster the use of these and other evidence-based care models in order to improve the quality of care and reduce readmissions rates for high-risk fee-forservice Medicare beneficiaries, and to document measurable savings to the Medicare program. an overall 30-day readmission rate of less than 10 percent for patients who completed CCTP services administered through the program, as compared to a baseline of all Medicare patients in that same service area of nearly 19 percent. While these initial successes demonstrate the power of improving care transitions and the important strides the CCTP is making, there are several challenges with the implementation of the program that are a proving to be barriers to more consistent progress across all of the CCTP sites. CURRENT STATUS The CCTP is run through the Center for Medicare and Medicaid Innovation. Initially, $500 million was authorized over five years for eligible community-based organizations (CBOs) that partner with acute-care hospitals to provide care transition services to manage Medicare patients' transitions and improve their quality of care. Unfortunately, in March 2013, appropriators stripped $200 million from the program. This occurred at the eleventh hour without sufficient congressional consideration. To date, there are 102 CCTP sites in 40 states across the country aiming to provide 700,000 Medicare beneficiaries with critical care transitions services. Many participating sites are seeing significant progress in effectively managing the transitions of high-risk beneficiaries and are achieving positive results from their interventions to assist high-risk Medicare patients with care transitions. For example, one CCTP program implemented a telephonic-based, social worker-led interdisciplinary team to intervene with high-risk beneficiaries following hospital discharge. Over 14 months, this model successfully decreased 30-day readmissions by 24.7 percent for approximately 1,400 patients in the host university medical center. In addition, one CCTP recently reported 14 CMSA TODAY Issue 5 * 2014 * DIGITAL CHALLENGES As detailed above, while many CCTP sites are seeing positive results in reducing readmissions and improving patient outcomes, some sites are having difficulty meeting the 20 percent readmissions reduction requirement within the designated two-year time frame. This is due to a number of challenges including: 1 LOW ENROLLMENT: Many sites are having difficulty meeting their enrollment benchmarks, which in turn has a direct, adverse impact on the targeted readmissions measure. This is a result of: * Confusion regarding CCTP and other ACA programs. Many hospitals perceive that their participation in other CMS-sponsored payment demonstrations, such as bundled payment or shared savings programs, precludes them from partnering with CBOs under the CCTP program. Although CMS has stated that qualifying hospitals participating in other programs are not excluded from the CCTP, further education is needed. Without active engagement in the partnership by the hospital, a CBO cannot achieve the CCTP goals, as it won't be able to identify and enroll the most appropriate patients, which is obviously an enrollment challenge.

Table of Contents for the Digital Edition of CMSA Today - Issue 5, 2014

President’s Letter
Association News
CMSA Corporate Partners
The Community-Based Care Transitions Program
Ready or Not
The Final Step: Remembering to Revitalize
Child and Adolescent Psychiatric Systems
Index of Advertisers

CMSA Today - Issue 5, 2014