Eager to apply for Community-Based Care Transitions Program (CCTP) funds from the Centers for Medicare and Medicaid (CMS)? CMS is equally eager to make awards. Aiming to encourage organizations to apply to the final round of the CCTP funding, CMS sponsored a 90-minute webinar that featured tips from program administrators on how to write a winning application, along with insights from communities that have recently been funded. The webinar offered just about everything applicants need to know to be successful. It highlighted insights on what to do—and what to avoid—as you pull together a team and submit your application.
CMS Chief Medical Officer Paul McGann, MD, introduced the session by stating that, in terms of the Partnership for Patients (PFP), the 3026 program is critical to helping CMS achieve its goals to improve patient safety while reducing costs. He noted that the program is the first-time ever that communities have been invited to define and price a Medicare benefit. The program represents an opportunity for organizations coordinate and collaborate to deliver services that help residents experience better health outcomes. It is, he said, “a new way of reaching out.” The webinar represented CMS’ effort to push out as much information as it can so that organizations can successfully apply to become CCTP communities. A final round of funding decisions will be made in late September. To be considered, applications must be received no later than close of business on September 3, 2012.
Details about application requirements and parameters can be found on the CMS Innovations website at http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html. In addition to providing an overview of the program, the site includes links to the RFP, the application package, and the budget worksheet. In general, to be eligible, programs must represent a partnership between an acute care hospital and a community-based organization; if it is the anchoring organization, the acute care hospital must be on CMS’ list of high readmit hospitals. Otherwise, it need not be. CBOs must provide care transitions services. They must have a governing board that includes consumer representation, they must be non-profits, they must be located in the community they aim to serve, and they must have previous experience in care transitions work. Closed systems—those in which, for example, a hospital and a home care agency are part of the same organization—are not eligible to apply. Preference is given to applications that include organizations supported by the Administration for Community Living (ACL, formerly the Administration on Aging), and that serve medically underserved and rural areas.
Successful applicants from around the country talked about various aspects of their applications and their work. These groups included P2 collaborative from Western New York, Carondolet in Arizona, Age Options in Illinois, and Delaware County, Pennsylvania. Potential applicants would do well to read the one-page summaries written by each of these sites and posted at: http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html . In the coming weeks, MediCaring aims to interview staff at each of these sites to learn more about what made their applications stand out, and what they plan to do in the coming years.
Ashley Ridlon of CMS described some of the lessons learned by organizations that have already successfully applied to the program. These organizations have found that a number of factors contribute to readmission, including those on the individual level, as well as those on a systems level. Individual problems include poor patient-provider interactions, medication mismanagement, and avoidable returns to the emergency department. Systems-level problems include the absence of standardized forms and processes, poor cross-setting communication, and a failure to “activate” patients—to ensure that they are engaged and informed partners in their care. The root cause analysis required by the CCTP application process is designed to help communities uncover their own problems and gaps in care transitions, and to consider and implement relevant interventions. This process is at the heart of a successful CCTP application. Ridlon emphasized that applicants must conduct “community-specific root cause analyses,” and develop an implementation plan that is in line with those findings. She also noted that those plans need to align with other care transitions activities currently available in a community. In addition, relevant, documented experience providing care transitions services is essential to writing a successful application. In describing that experience, CMS urged applicants to be explicit with details, describing not only reductions in readmissions, but methodology, evaluation, characteristics of patients enrolled (or not enrolled), and outcomes. They should also describe in detail any care transitions training their staff have received—who participated, when and where, and how others will be trained.
Ridlon urged participants to engage their CMS Regional Quality Improvement Organizations (QIOs), an invaluable resource. QIOs can help applicants to conduct their root cause analyses, collect data, identify partners, arrange meetings, and select interventions.
Juliana Tiongson, also of CMS, described issues surrounding the budget process. It is essential that applicants read and understand what the RFP calls for. To some extent, the program can be defined, budget-wise, by what it is not: It will not pay for services already required by Medicare’s conditions of participation. It is not a grant program. It will not pay for activities that are not directly related to providing services to beneficiaries. It will not support ongoing care management or disease management. Many applicants, Tiongson said, have completed the required budget worksheet, but fail to complete the equally important budget narrative, outlining at length exactly what is to be covered by the program’s blended rate. She also noted—and this is critical—that that rate is not likely to be competitive if the blended per-person rate is over $400.
The blended rate is not a set figure. It will vary by community and by intervention. Patient volume and expected reductions in savings will also affect the blended rate.
Tiongson listed a series of pitfalls about which applicants should be wary. These include:
- Partnering with an ineligible CBO, or being unclear about the CBO’s structure. Problems include not identifying board members, not including consumers on the board, failing to complete audit forms, or being part of a closed system.
- Failing to conduct a community-specific root cause analysis.
- Completing the root cause analysis, but failing to describe the methodology behind it.
- Failing to link the root cause analysis findings directly to the selected care transitions intervention.
- Not having all required signatures on all required letters of commitment.
- Not including the budget narrative along with the budget worksheet.
- Providing insufficient detail on everything from the budget to staff training.
- Being overly broad or subjective about the target population.
- Not describing the readmission risk assessment tool.
- Proposing hybrid intervention models that have not been tested, or using bits and pieces of various interventions to come up with something new and untested.
- Being fuzzy about the nature of relationships, and being unclear about how fees will be shared among the partnership.
- Not listing board members and not including consumers on those boards.
- Being too slow to get started—at the very most, organizations should take three months to hit the ground running. More than that is too slow for CMS’ purposes.
In terms of the budget itself, Tiongson noted several errors that applicants have made, including:
- Using a per member per month rate, rather than a per eligible discharge
- Failing to include the budget narrative
- Basing the rate on 100% participation of the target population
- Making unreasonable assumptions about the number of admissions avoided, which inflates the savings estimates (CMS recommends assuming a 20% reduction over two years as a reasonable expectation)
- Building the budget as a grant application, rather than as a per-eligible-discharge fee
- Offering providers financial incentives to participate.
In closing, Ridlon and Tiongson suggested that applicants reflect on the following points as they develop their applications:
- Focus on implementing an effective intervention closely tied to the findings of the community-specific root cause analysis
- Consider collaborating with other payers, including the private sector, Medicaid, and Medicare Advantage programs
- Build strategic partnerships in communities to bridge gaps, and encourage members to share resources and learn from one another.
For a sample partnership agreement, follow this link: https://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/CCTP_Program_Agreement.pdf. To view the entire slide deck, visit the July 12 blog posting on MediCaring.org, which links to the PDF.
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Key words: CMS, CCTP, Section 3026, care transitions, applications, strategic planning, program implementation, budget, QIO, CFMC