By Robyn Golden and Gayle Shier

Recent federal investments in care transitions show that the government is placing a high priority on this issue on a national level, as demonstrated in three prominent programs launched as provisions of the Affordable Care Act (ACA).

First is the Community-Based Care Transitions Program (CCTP) (Section 3026), which financially supports community-based organizations providing care transitions services in order to determine if this method reduces re-admissions, improves quality of care, and yields cost savings for Medicare. This program works in concert with the Hospital Readmissions Reduction Program (Section 3025), which reduces Medicare payments for hospitals with excess re-admissions—excess being defined by published federal regulations. Lastly, the Partnership for Patients, a national public-private collaboration launched in April 2011, created the Center for Medicare & Medicaid Services’ (CMS) Center for Medicare & Medicaid Innovation, which seeks to achieve two goals: to promote patient safety and to allow patients to heal without complication.

These ACA provisions build on prior work initiated by CMS’s last three-year contract with the Quality Improvement Organizations (QIO). These organizations are charged with improving care for Medicare beneficiaries. Included in the 9th Scope of Work, the last contract ran under a “care transitions theme,” which created the structure for piloting care transitions programs in fourteen communities. This work showed the need for and promise of care transitions. 

In addition to the QIO’s work, these ACA provisions build upon early support of care transitions awarded to Area Agencies on Aging (AAA) and Aging and Disability Resource Centers (ADRC) by the Administration on Aging (now called the Administration for Community Living [ACL]). Findings from both the QIOs and the ACL’s program inform current work around care transitions.

The Community-Based Care Transitions Program

The Community-Based Care Transitions Program was initiated in 2011, and has forty-seven awardees. Models used in the CCTP must be evidence-based, and programs must involve both hospitals and community-based providers, many of whom were formerly competitors for services funded by Medicare. The program is designed to promote involvement of social services or home- and community-based providers in transitions from one setting to another, and collaboration of multiple providers engaged in a patient’s care.

Under the agreement, awardees receive a two-year cooperative agreement, which may be renewed for the duration of the five-year program, contingent upon program outcomes (a projected 20 percent, thirty-day re-admissions reduction). During this time, awardees can bill Medicare for an agreed upon per eligible−discharge rate payment for care transitions provided, no more than once in a 180-day period. Awardees also agree to participate in a quarterly learning collaborative with others engaged in the program. They share best practices, discuss challenges, and provide each other with technical assistance that can effect refinements of care delivery for maximizing positive outcomes.

The forty-seven awardees’ programs vary vastly in geography and structure (for more details visit the program website). The programs vary from small rural community hospitals to large urban academic medical centers. The community agencies involved range from AAAs and ADRCs to faith-based providers and Federally Qualified Health Centers, and more. The following are three examples of promising care transitions programs:

• Carondelet Chronic Care Navigation Program is using the Project RED model to improve transitions throughout both urban and rural areas of southern Arizona in a largely Hispanic and Spanish-speaking population. This program is emerging from a faith-based integrated healthcare delivery network working in conjunction with a community-based council on aging to provide social services, and a university that provides high-level training. The team is also using a Web-based health information technology platform for communication across settings.
• Michigan Area Agency on Aging 1-B is delivering care through Coleman’s Care Transitions Intervention to Medicare fee-for-service beneficiaries in a medically underserved area surrounding Detroit. Coordinated by an AAA, the program team also includes representatives from hospitals, nursing homes, a personal emergency response provider, hospice, the state’s QIO, a Six Sigma quality improvement organization, and visiting physicians.
• Delaware County Office of Services for the Aging is using a modified version of Naylor’s Transitional Care Model and delivering care in a densely populated area in southwest suburban Philadelphia. The program involves five of the county’s six acute care hospitals and builds off work done previously as an ACL-ADRC program grantee. The program uses registered nurses and social workers to smooth transitions between settings.

A more detailed look at a CCTP awardee using another transitions model, Bridge, is included in this issue (see the Altfeld et al. article). The CMS will evaluate the awardees’ program outcomes across their five-year duration and release lessons learned to the broader public. The CCTP program is still open to new applicants, and review occurs on a rolling basis until the $500 million allocated to CCTP is dispersed. 

Other Programs to Watch

In addition to the CCTP, important work in care transitions is occurring with the QIO’s 10th Scope of Work—the QIO’s current three-year contract. Beginning in August 2011, the 10th Scope of Work established the Integrating Care for Populations Aim, calling for improvement of care transitions in all fifty states using admission and re-admission rates per zip code as a measure of impact. This program encourages establishing formal partnerships between stakeholders that are committed to improving care through coalition charters. Communities involved in the Aim are performing root-cause analyses to strategize their approach to care improvement and implementing evidence-based programs to address these causes.

The CCTP and the 10th Scope of Work are encompassed in the Partnership for Patients. One important additional component of this Partnership relevant to care transitions is the Hospital Engagement Networks (HEN). Twenty-six HENs have been created, and funded with $218 million. These HENs, selected through a competitive process, represent networks of hospital systems, hospital associations, and quality organizations on state and national levels. They are responsible for identifying and disseminating models that make healthcare safer for patients.

All of these programs come together to form an infrastructure for quality improvement that is anticipated to continue even after the CCTP’s five years have ended. The outcomes of these programs will dictate how care is provided across transitions well into the future as best practices are determined and disseminated, the lessons are shared with those providing care outside the awardees and coalitions, and what is currently seen as innovation becomes routine.

Robyn Golden, A.C.S.W., L.C.S.W., M.A., a former chair of ASA’s Board of Directors, is director of Health and Aging, Rush University Medical Center, Chicago, Illinois. Gayle Shier, M.S.W., is program coordinator, Health and Aging, Rush University Medical Center.

Editor’s Note: This article is taken from the Winter 2012-2013 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “Care Transitions in an Aging America” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generationssubscribers at MetaPress.