CMS Awards First Care-Transition Coalition Grants


Piedmont Hospital in Atlanta is one of several hospitals participating in SHM’s care-transitions initiative Project BOOST (Better Outcomes for Older Adults through Safe Transitions) to be included in the first round of Community-Based Care Transitions Project (CCTP) awards.

Matthew Schreiber, MD, vice president and chief medical officer for Piedmont Hospital, says hospitalists should look for ways to participate in the community coalitions applying for CCTP awards, because managing their hospitals’ readmissions rates eventually will be essential to their job security.

“I said to my hospital, ‘Right now, people are giving out money for us to be in the figuring-it-out mode regarding readmissions,” Dr. Schreiber explains. “Eventually, we’ll just have to do it anyway.’”

CCTP is part of the government’s efforts (PDF) to reduce hospital readmissions by encouraging coalitions of health providers to collaborate on care transitions and ongoing care coordination after patients leave the hospital. The $500 million program initially dished out seven awards to community-based coalitions, not directly to hospitals. Most of these coalitions are housed at regional Agencies on Aging and involve multiple hospitals or health systems.

According to the Centers for Medicare & Medicaid Services (CMS), CCTP differs from a traditional grant program in that it pays community-based organizations an all-inclusive rate per eligible discharge, based on the cost of care transition services and of systemic changes at the hospital level.

The seven awardees also employ the Care Transitions Intervention program developed by Eric Coleman, MD, MPH, of the University of Colorado, co-chair of Project BOOST’s national advisory board. The intervention program is a recognized tool for improving care transitions and reducing preventable rehospitalizations through the use of social worker "transition coaches" to provide discharged patients with self-care education and encouragement.

Other BOOST site hospitals participating in CCTP-awarded coalitions include Northwestern Memorial in Chicago and Emory University Hospital Midtown in Atlanta.

Dr. Schreiber says being a Project BOOST site and using Dr. Coleman's Care Transitions Intervention should be complementary for any hospital striving to reduce readmissions. “Both together were greater than the sum of their parts,” he says, adding that Piedmont has reduced its readmission rate by 50%.

Summaries of the first seven sites and information on how to apply for ongoing CCTP grants can be found here.

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