CMS Announces Guidelines for $500M Care Transitions Program


An eagerly awaited federal grant program that will allocate $500 million for improving care transitions and reducing rehospitalizations will soon release a solicitation and application instructions, possibly by the end of December.

The Community-Based Care Transitions Program (CCTP), funded for five years starting in January through the Affordable Care Act, is open to hospitals with higher-than-average rehospitalization rates and their community-based partners, and to coalitions of community-based organizations that include hospitals, CMS research analyst Juliana Tiongson explained during an all-day conference Dec. 3 in Baltimore.

Hospitalists and HM groups likely would not qualify directly for these grants, but they can start identifying and partnering with interested hospital leaders and relevant community-based providers. CCTP is designed to encourage communities to work together in ongoing learning collaboratives, drawing on evidence-based models for improving care transitions, Tiongson said. Examples of evidence-based strategies, such as Eric Coleman’s Community Care Transitions Program, Mary Naylor’s Transitional Care Model, and SHM’s Project BOOST, were described during the teleconference.

“We will require applicants to do their homework, including a thorough root cause analysis” of current care-transitions processes and their limitations, Tiongson said. Applications that include multiple stakeholders across the healthcare continuum, such as consumer representation, links to accountable-care organizations (ACOs), and medical homes, and those that are based in the communities they propose to serve, will be favored in the rolling application process. Applicants should demonstrate organizational readiness in terms of staffing, training, and preparation for better managing such transitions as hospital discharges.

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