May 292012

A recently released SCAN Foundation white paper summarizes a daylong conference aimed at helping organizations to understand and complete applications for the Centers for Medicare and Medicaid (CMS) Community-based Care Transitions Program (CCTP). The report features advice and guidance provided during a March 2012 program sponsored by the Southern California Patient Safety Collaborative; the event included experts from the Hospital Association of Southern California; Health Services Advisory Group of California, Collaborative Healthcare Strategies, Collaborative Consulting, and recent CCTP applicants. Part of the program focused on how to navigate the CCTP application process, and the report summarizes that process, and offers  tips on how to address common concerns and challenges.

Panelists identified four key themes that organizations need to address in the application process, including:

  • Conducting a root cause analysis and developing a program strategy
  • Developing a budget/calculating the blended rate
  • Hiring a grant writer
  • Building relationships

The report explains the purpose of the root cause analysis, which is to “identify gaps in care, new target populations, cultural and linguistic barriers, communication challenges, and many other barriers to a smooth post-hospital transition that are specific to the community and target population.” The report  describes how some recent applicants have used the root cause analysis to develop programs; one, for instance, found that medication reconciliation was  a major issue, and developed a program that targeted medication management very soon after discharge. In terms of developing the program strategy, panelists urged applicants to “use a simplified [care transitions] model and not make their intervention too complicated.” They also urged applicants to conduct small, pilot projects implementing evidence-based models, a critical step in  demonstrating past success with care transitions work.

In addition, the report provides very detailed information on how to develop and present the project’s budget, along with other financial tips, including how to calculate the blended rate. Here, panelists suggested that applicants develop two budgets—one that includes the entire cost of the intervention, and one that is designed for the CCTP opportunity, and addresses only direct service costs. The report notes that, to date, funded organizations have received from $250 to $500 per eligible patient, and adds, “CCTP is not a money-making venture, but could significantly help improve the quality of life for participants and supplement in-house costs to pay for improved care transitions.”

Calculating the blended rate has proven to be a challenge for many organizations. The report offers very specific information on calculating it, as well as how to calculate the target population number.  In short, as applicants develop their budgets, the report recommends that applicants consider the  following questions: What is in it for CMS? How is it going to save them money and keep people out of the hospital, and improve the Triple Aim? What does this [project] mean for CMS?

Some organizations have hired professional grant writers to help them develop their applications; such a person can: help organizations to put their ideas into language appropriate for CMS,  ask questions that help to clarify the program, and ask questions that help to develop the budget. In addition to working with professional grantwriters, organizations should also consider having their applications reviewed and critiqued by external partners, or others with no stake in the application.

Finally, the report notes CMS’ strong preference for applications that “indicate the involvement of multiple hospitals in their community, led by an eligible CBO.” As groups build such relationships, they should consider all community organizations that influence and affect patient lives, with particular attention to gaps in care identified by the root cause analysis and groups that might fill them.

The full report, by writer Patrice Wagonhurst, can be downloaded from the SCAN Foundation website at:

 Key words: CCTP, Section 3026, blended rate calculation, grant application

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