Nov 302011

In a national conference call with the first 7 sites to be awarded CCTP funding, representatives from each pointed to common elements that characterized their winning applications. (For details about each of the selected sites, go to and search for CCTP; that will lead you to  project summaries and a complete list of recipients.) In addition, CMS has posted a new advisory for potential applicants at:

During the call, each site described programs  rooted in the development of a broad-based community coalition with experience in working on improving care transitions, and in the development and implementation of interventions closely linked to results of the root cause analysis.  Each described previous experience in working to improve care transitions, often through pilot projects and demonstrations, and extensive community-based involvement in the efforts. Each group described programs that work across multiple hospitals and health care systems, reaching a broad area of diverse populations, in most cases, spanning several counties or towns.

Dr. Paul McGann noted the importance of the CCTP program in fostering relationships, linking community-based organizations to the broader health care system. He said, “The current health care system makes it hard to do the right thing for patients. These care transition projects are the start of healing the health care system, of making it easy to do the right thing for patients.”

For the call, a representative from each site briefly highlighted some aspect of its application or proposed program; their overviews are summarized below.

The Southern Maine Agency on Aging/Aging and Disability Resource Center, described its work to closely tie results of its root cause analysis to the interventions it proposed.

The Atlanta Community-Based Care Transitions Program focused on its work to establish a community coalition and develop partnerships, pointing to its work to develop a program anchored by three sets of partners: six carefully chosen hospitals, the Georgia QIO, and community-based organizations. Atlanta noted that when it began the application process, it did not immediately seek out hospital CEOs, but rather relied on existing relationships with hospital staff, who then “took it up the ladder,” until CEOs were on board and invested.

Elder Services of the Merimack Valley, which serves areas  in New Hampshire and Massachusetts focused on its work to conduct root cause analysis (RCA) linked to a targeted intervention. Its analysis, which included focus groups with people from across the continuum, pointed to seven factors that impede good transitions. It then matched its intervention to the problems the RCA uncovered.

The Southwest Ohio  Care Transitions Collaborative explained how it selected its target population of high risk patients, who they define as Medicare fee-for-service beneficiaries with one of three common diagnoses: heart failure, heart attack, or pneumonia. Using data from a pilot program, the team identified common conditions and patient factors (e.g., whether they were coming from home, hospital, or SNF).

The Area Agency on Aging, Region One, serving Maricopa County, AZ, focused on its previous work with care transitions, and lessons it had learned in the course of conducting pilot projects. Based on this work, the team found strengths and weaknesses in its approach, and therefore altered published interventions to match particular community needs.

The Council for Jewish Elderly, based in Chicago, described the structure of its organization, and how it met the application’s eligibility criteria. In particular, the team walked through specific details of its long history in the community, providing a tradition of  “community-focused and patient-centered care.” In its application, it walked through specific elements of its forty-year history in the community. It built a team that included hospitals that had demonstrated their commitment to the issue, primarily through their use of Project BOOST or Project RED.

Finally, the Akron,/Canton Area Agency on Aging  described its previous experience in improving care transitions. In a pilot program with hospitals, the team had already demonstrated success in reducing readmissions; the issue it faced was in the sustainability of that program.  The group’s intervention features an interdisciplinary team that meets to propose solutions to complex, difficult cases.

The call concluded with a quick wrap-up by Juliana Tiongson, the CMS staff member who leads the program who reminded potential applicants to focus on several elements in their applications, and noted that CMS has a strong preference for applications that indicate the involvement of multiple hospitals and their community, led by an eligible community-based organization (CBO). Applicants should focus on their previous experience in care transitions work, take care with their root cause analysis, and evidence consumer involvement on boards. Finally, applicants should know that their programs need not be limited by patient diagnosis; rather, interventions should clearly be tied to community patterns and needs. She also noted that there was preference for applications that include multi-hospitals and CBOs in the coalition, and that single hospital sites would likely be limited to those serving very rural communities.

The presentation did not deal with the many questions on setting the blended rate, except to say again that this is not a grant program and that indirect costs and training and start-up costs should not be included. The application process is ongoing, and CMS regularly convenes panels to review applicants as they come in on a rolling basis.


Key Words: CCTP sites, Section 3026, care transitions, CMS site awards, technical assistance

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