CMS is accepting applications for participation in the Medicare Community-based Care Transitions Program (CCTP). The CCTP, mandated by section 3026 of the Affordable Care Act, provides funding to test models for improving care transitions for high-risk Medicare beneficiaries. As stated in the solicitation, the goals of the CCTP “are to improve the quality of care transitions, reduce readmissions for high risk Medicare beneficiaries, and document measurable savings to the Medicare program by reducing unnecessary readmissions.”

Entities eligible to participate in this program are statutorily defined under section 3026 of the Affordable Care Act to include subsection (d) hospitals with high readmission rates that partner with community-based organizations (CBOs) or CBOs that provide care transition services. CBOs are defined as community-based organizations that provide care transition services across the continuum of care through arrangements with subsection (d) hospitals and whose governing bodies include sufficient representation of multiple health care stakeholders, including consumers.

While the CCTP will run for five years, beginning April 11, 2011, participants will be awarded two-year agreements that may be extended on an annual basis for the remaining three years based on performance. The solicitation indicates that proposals will be accepted on a rolling basis and that “a competitive process will be used to select eligible organizations.” In selecting CBOs to participate in CCTP, the Affordable Care Act requires that preference be given to eligible entities that are Administration on Aging grantees that provide concurrent care transition interventions with multiple hospitals and practitioners or entities that provide services to medically-underserved populations, small communities, and rural areas. In addition, the solicitation indicates that consideration will also be given to organizations that have established similar care transition interventions with State Medicaid programs and organizations that have established relationships with Medicare Advantage plans and commercial health plans as part of a comprehensive all-payer approach to readmission reduction.

As outlined in the solicitation, applicants must: (1) identify root causes of readmission and define their target populations and strategies for identifying high-risk patients; (2) specify care transition interventions (including strategies for improving provider communications and patient activation); and (3) provide a budget including a per eligible discharge rate for care transition service, an implementation plan with milestones, and demonstrated prior experience with effectively managing care transition services and reducing readmissions. For further details on the CCTP and the application process, please click here to access the solicitation