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Federal agency guidance

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This section authorizes the Medicare Community-based Care Transitions Program (CCTP) designed to improve the quality of care transitions, reduce readmissions for high risk Medicare beneficiaries, and document measureable savings to the Medicare program by reducing unnecessary readmissions. The Secretary of HHS will provide funding to eligible entities that furnish improved care transition services to high-risk Medicare beneficiaries.

Eligible entities include hospitals with high readmission rates and community-based organizations that provide care transition services across the continuum of care through arrangements with hospitals and whose governing bodies include sufficient representation of multiple health care stakeholders, including consumers.

If an eligible entity is a hospital, the hospital must enter into a partnership with a community-based organization to participate in the program.

Application and Participation

Eligible entities wishing to participate in the program must submit an application to the Secretary of HHS which includes a detailed proposal for at least 1 care transition intervention, which may include the following:

  • Initiating care transition services for a high-risk Medicare beneficiary not later than 24 hours prior to the discharge of the beneficiary from the eligible entity.
  • Arranging timely post-discharge follow-up services to the high-risk Medicare beneficiary to provide the beneficiary with information regarding responding to symptoms that may indicate additional health problems or a deteriorating condition.
  • Providing the high-risk Medicare beneficiary with assistance to ensure productive and timely interactions between patients and post-acute and outpatient providers.
  • Assessing and actively engaging with a hig-hrisk Medicare beneficiary through the provision of self-management support and relevant information that is specific to the beneficiary’s condition.
  • Conducting comprehensive medication review and management (including, if appropriate, counseling and self-management support).