Community-based Care Transitions Program provides key insights to inform continued health and social care integration

Enacted as part of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) launched the five-year groundbreaking demonstration program Community-based Care Transitions Program (CCTP). CCTP was the agency’s first initiative to provide community-based organizations (CBOs) with funding to provide services to manage Medicare beneficiaries' transitions from hospital to home. Across the country, CCTP participants had lower readmission rates and Medicare expenditures when active in the program, relative to the evaluator’s matched comparison sites. However, the evaluation did not include a specific analysis of the impact of the CBO’s interventions and did not identify a causal or longer-term impact of the demonstration.

Yet, CBO participants report that CCTP opened the door for key structural improvements to the way that health care and care transition services are coordinated and delivered in their communities.

This survey, conducted by members of the National Coalition on Care Coordination (N3C), collects CBO experiences on successes of their CCTP efforts, the challenges they faced, and longer-term structural results that followed their participation in the CCTP demonstration. While the CCTP demonstration program has concluded, survey responses provide information that can be useful for growing and communicating about cross-sector care transition programs in the future.

Click here to access the survey synthesis.